Saturday 26 February 2011

Friday 25 February 2011


One of my patients with dementia has a son in a low secure forensic unit. I met the son to share news on how his mother's faring, wanting to maintain the family involvement in mum's care now she's becoming increasingly confused. The son's Consultant Psychiatrist felt I should share the news episodically (rather than other family members talking with him) so it could be done sensitively without de-stabilising the son's mental wellbeing.

I've mixed views on that.

Okay, I'm used to breaking bad news. Telling someone they have dementia, and what that will do to them, is hardly a cheery act. I share news and discussion and seek input into formulation and decision making from patients and families every day. Speaking with a son about his monther's deterioration, about current options, about future considerations, without causing excessive upset, that I'm happy to do.

But don't his brothers and sister know him far better, aren't they just as capable/more capable to talk with him about their mother and from the options currently considered to then collectively form a coherent family concensus on suggestions of how care could be?

Anyway, I talk with the family and all's affably agreed, on this occasion, with fairly clear views of what's the best way medication options and residence and care package for their mother.

Whilst talking this through with the son, we discussed antipsychotic medication and how this had been tried but was unhelpful in his mother's care, so had been withdrawn. The side effects were significant, the benefit slight, so the decision was simple enough. The son, though, was ineterested. He was on similar medication, being given antipsychotic medication daily, which he felt was causing adverse side effects.

He wanted to discuss his medication, his experiences of how it felt, his side effects, his options for other drugs. I'm not his psychiatrist, I really can't do that. But I can't just ignore him. I ended up sharing my views on what some people find the benefits to be, what side effects could be related to medication, but ultimately it's between him and his own psychiatrist to make sense of how medication supports his care. I wrote to his Consultant Psychiatrist about what we'd discussed (both of his family and incidentally the concerns he'd disclosed on his medication) so hopefully everyone's informed on all issues.

Although there to support his mother's care, it seems fair for a Consultant Psychiatrist not to direct care/give an opinion but to proffer a little information, when asked to do so. Odd that boundaries of care are so explicit that it feels a little racy to do so!

Wednesday 16 February 2011

Covert Medication

Do we use this enough?

At the moment I've no patients who are receiving medication covertly. I have lots of patients who have a mental disorder, within the meaning of the ammended Mental Health Act 1983. I have lots of patients who have an impairment of, or a disturbance in the functioning of, the mind or brain, as set out within section 2(1) of the Mental Capacity Act 2005. In fact all of my patient can fit in to one of the categories of mental disorder/impairment/disturbance of mind/brain.

It was put to me that since all my patients are mentally unwell, if they stop taking medication, can't they be made to take medication? Well no, no they all can't. But it got me thinking that yes, some of the could, but I don't force this. This led to me being chided for not treating vulnerable patients who couldn't make valid choices on treatment.

If you're in a care home or hospital, say, and you have dementia, you probably are fine to make valid decisions on medication you're offered/continue to take. But you might struggle to make valid decisions on medication as dementia progresses or when you have a UTI, chest infection, constipation, pain, dehydration or other cause for acute confusion that makes your thinking worse.

What happens then?

Usually medication's offered to you, even though you're confused and can't give/withhold valid consent on the use of medication. If you accept it, you keep receiving it. If you refuse it, you're allowed to and it's documented as declined and you don't get medication. So whether you receive medication or not isn't based on clinical decision making, it's based on how stroppy you seem and how much nurses/care assistants respond to this. In acute wards it's also about pressures on qualified nurses' time which is now so pressured that even if staff wanted to sit down and explain/support a confused patient with medication, they don't have the 20 to 30 minutes that might take.

The pharmacist and manager givig me grief over this were reckoning that this arbitary giving/not giving medication on how compliant/stroppy a patient is seen to be isn't good. It should be on clinical evidence. If someone is confused and can't give (or withhold) valid consent, they're managed under the Mental Capacity Act 2005 framework and medication can be given when this is in their best interests. Rather than not giving it, the least restrictive means should be used. Instead of section 3 and depot antipsychotic given under Part IV of the MHA 1983, wouldn't orodispersible olanzapine in their tea be a much better option?

I rarely advocate for covert medication to be used. Maybe I'm wrong.

Tuesday 1 February 2011


I work with a lot of people.

Or more accurately, as I'm oft times reminded, I meet with a lot of people and they do a lot of work.

One area of work is prescribing. I'm a doctor, doctors have expertise in this area. Psychiatric drugs are contentious, I'm a psychiatrist so can inform on reasoned, evidence based rational prescribing practice. This means I'm often asked to attend Local Authority or PCT or APC meetings to talk through how medication should/shouldn't be used.

This has contributed to significant improvements.

Patients can access any class of drug without constraints placed upon prescribers, rather than being totally protocol driven our patients can access drugs at any stage of illness (so we can freely prescribe outwith NICE guidance), our use of contentious drugs (such as antipsychotics in dementia) is audited and is seen to be good, use of medication in care homes has dropped markedly with rich mental health staff input instead, Local Authority has funded use of support workers/day care to reduce carer stress (and reduce medication through staff input as a viable alternative), GPs 'phone me up for advice or drop a short letter with all the details as well as making formal referrals for input.

Over the last few years things have got a lot better in my corner, with much better medicines management.

A recent PCT meeting I was invited to caused concern. The folk advancing all the work to progress sensible care were no longer in post, within either the Local Authority or the PCT. With the writing on the wall for PCTs, everyone's leaving, sharpish. With Local Authority not able to cut front line Assessment Officers/Social Workers unless they're not needed (and they are!) it's managers/decision makers who're being lost.

But in this state of flux, work that's been gently but purposefully progressing for the last few years now comes to a hiatus.

In this brave new world of austerity and GP consortia, will it all get better, once again?