Saturday 28 July 2007

Liaison Psychiatry

A routine liaison referral

I was asked to see a widowed elderly lady who has almost certainly has had an anterolateral myocardial infarction (a heart attack). She's on the medical wards and, thankfully, is doing well. I know her reasonably well from prior home visits.

A few weeks before this . . .

Prior to this miserable event she enjoyed good health but had become depressed. A mixture of social isolation, loneliness, loss of friends (many passing away), loss of fitness (no longer able to potter and enjoy her garden as she used to), increasing frailty and the bitter loss of her close husband all contributed to a pretty low mood.

Some of her low mood is understandable. Anyone in her situation would feel pretty despondent. As such, that's normal human emotion, that's sadness and upset, that's not an illness. Unpleasant, yes. Psychological disturbance, yes. Unwanted, yes. Psychiatric illness, no.

But her mood became more than just sadness, it started affecting her well being. Appetite faded away, weight started to fall off her already slight frame. She couldn't get to sleep (and no pain or other problem stops her). She'd awake early, with feels of disquiet, then sadly couldn't find solace in sleep again. The mornings were hard; she had thoughts of a full day to fill, to endure. When awake she'd not feel refreshed, she was still exhausted (but not sleepy). She had ideas of doing things (sorting bills, writing to a friend she used to go to the theatre with) but isn't quite motivated enough to do so. She no longer wore lipstick, she always used to.

She had other features that were sufficient for a very sensible GP To start an antidepressant, which didn't work, so she then referred the lady on to me. Trying an SSRI antidepressant then reviewing this and supporting the patient with frequent contact . . . I am blessed with many excellent GP colleagues in my area.

I swapped her to a new antidepressant which rather pleasingly for all of us has been successful. The medication is venlafaxine XL, easily taken once a day, it helped her feelings of ill ease and anxiety as well as her low mood. Things started to improve.


She has written to her friend. She is making plans for the future, reading through the programme that's still posted to her each season and suggesting they go to the theatre this Summer. She's eating better. She remembers her medication. She's able to tell me what she's been watching on television and reading in her novels and how family are faring (since she is once again interested enough to 'phone them up).

Medical care

She was admitted under the care of the medics at our local District General Hospital. She has, it seems, received good care. They rightly are worried. Use of venlafaxine is cautioned in heart disease and contraindicated in conditions with a high risk of abnormal heart rythms. Review of the use of venlafaxine is indeed a sensible request. The medical team faxed a request to me from their hospital which I received in the morning, asking me to liaise with them in her care. A sensible liaison referral.

I drove on over at lunchtime to see the lady and review the risks, benefits and alternatives around her medication.

Liaison psychiatry

20 minutes driving there. 15 minutes driving around the district general hospital site looking for somewhere to park. 10 minutes kerb crawling around the nearby streets seeking somewhere to park. No success. 20 minutes driving back to my base hospital.

A plea

I am sorry that, yesterday, I could not review this lady's care. I did try. Hearing Jeremy Vine on Radio 2 was a pleasing way to spend an hour or so but I'm sure it's neither what I'm being paid for nor what I've been trained to do.

We have no Service Level Agreement with the hospital, I'm foolishly providing my time to them for free. And attempting to see patients promptly. Despite this, they still can't put things in place enabling me to see their patients for them.

Surely, surely, there has to be a better way of doing this.

Friday 27 July 2007

Mental Capacity Act 2005

There's been a bit of sneaky legislation.

The Mental Capacity Act 2005

Have you had a rummage around through The Mental Capacity Act 2005 (MCA 2005) yet?

I've read it from cover to cover a couple times now, since it's highly relevant to my work, but even so it was only when a number of lawyers have explained some of it to me that the implications are becoming clear. And scary.

The legislation is broad. It doesn't apply just to mental health, or just to health in fact.

Question : When a social worker determines if a person can make decisions about going in to care, solicitor determines if I have capacity to instruct them on the conveyancing to buy a new house, when a bank clerk determines if someone's capable of managing their finances, whether a frail old lady in a care home can refuse a bath, what test is used in any and all circumstances to decide if I, or whoever, does have capacity to do these things?

Answer : The Mental Capacity Act 2005. It has within it the test that is used to assess capacity. Any capacity. In any situation. For anything. By anyone. So, a pretty big bit of legislation, then.

Good bits

No longer will social workers routinely be able to ask me if a patient on a medical or surgical ward, or in their own home, has capacity to make choices about going in to a care home. The social worker will have to determine that for themselves. It is not a delegable duty. Professionals taking responsiblity for their professional decisions, this is a good thing. Specialists still can give a view in complex cases but that doesn't over ride the decision any other individual makes on their own assessment of capacity.

Worrying bits

Let's assume that I've a patient who lacks capacity to make decisions about their future treatment. Maybe they're too depressed and thought disordered to weigh up choices, benefits, risks, consequences and outcomes of various alternatives. Maybe they're dementing through Alzheimer's disease. Within the meaning of the MCA 2005 this makes them an "incapacitated adult" with respect to this decision on treatment.

Section 5 lets us treat an incapacitated adult.

Positively, it means nurses and carers can deliver care lawfully. The patient needs dressing in a morning, may need help bathing, may need help dressing in nightwear on an evening. Section 5 lets them deliver this hands on care without this undressing of a patient without their consent constituting trespass against the person and criminal assault. Which is a good thing, carers are empowered to deliver care.

Worryingly, it means I can give any care on the understanding, ". . . that it will be in [the patient's] best interests for the act to be done."

The MCA 2005 covers personal welfare (health and social welfare) decisions.

If a muddled patient needs care (medical, nursing or social) such as, say, an injection, it could be given to the adult under the MCA 2005. In fact, ECT or any other treatment can be. Antibiotics, amputation, arthoplasty, whatever is needed and the patient's doesn't have capacity to consent to (but otherwise could consent to).

This effectively obliges us to use community treatment orders. When the MCA 2005 comes fully in to force this Autumn a psychotic patient who doesn't appreciate the role of medication can then have depot antipsychotic medication injected in to them in their own home without their consent.

The safeguards

They're not detained under the Mental Health Act 1983 (MHA 1983), they have none of the protections of the MHA 1983 and no scrutiny or review that the MHA 1983 requires.

An independent MCA advocate (IMCA) can give an opinion and a court appointed deputy can give a direction. If you've made a Lasting Power of Attorney (LPA) then your Donee can give or refuse consent for health and social welfare decisions, if you have empowered them to do so in the LPA. Nobody else can. In all other circumstances then other folks views are taken in to account but the only ones truly empowered and determining what is is the patient's best interests is the multi-disciplinary team.

So if I'm knocking on someone's door with a nurse to inject them in their own home, how can they appeal against this decision? No Mental Health Act Commission review. No second doctor needing another medical recommendation. No Second Opinion Act Doctor (SOAD) approving medication, ECT and so on. No right to appeal (to managers or to a Mental Health Act Commission tribunal). No right of relatives to discharge.

Hmmm, not many safeguards or rights at all, in fact . . .

A thought

1 in 4 of us will experience mental illness at some point in our lives.

Lest, in a moment of lost capacity, malign or unwanted care is benevolently foisted 'pon us, I reckon it's time for us to see our solicitors and sort out Advance Decisions and two Lasting Power of Attorneys (one for Personal Welfare and one for Property and Affairs).

Who's going to win here, then?

Solicitors must be ecstatic with glee.