It's not uncommon for folks to be prescribed medication to take when it's needed, rather than regularly at the same time each day.
Such medicine is prescribed with the accepted abbreviation PRN (pro re nata), i.e. when required.
Doesn't this get you thinking?
If I prescribe a drug PRN for one of my in-patients, it's not there to be used regularly (or I'd write it up regularly, at specified times). It's then wholly up to the nurse to decide if or when it's given.
Usually if I want a nurse to decide if the patient has a particular problem, then formulate presentations to conclude that pharmacological treatment is indicated, then determine that a drug I've suggested is the right drug for that patient with that problem at that time, then ensure my patient gets that drug, the nurse is a Supplementary Prescriber. She's done courses on therapeutics, pharacokinetics and dynamics and (critically) has ongoing teaching and ongoing individual supervision with me and mandatory attendance at our ongoing training programme and attendance at our non-medical prescribing forum.
Thus, for an experienced band 7 community to think, yes, this psychotic patient who is believing that "they are out to get me" and is 'phoning police a dozen times a day and daren't leave the house really could use some additional medication (that a Consultant has written in a Clinical Management Plan with the nurse) to de-escalate their distress and help them cope, they have a rigorous training and ongoing development programme.
For a less experienced band 5 ward nurse to think, yes, this psychotic patient is agitated and I'll settle them down with some additional medication (that a Consultant has written on a drug card with a nurse at the MDT), they have no scrutiny or guidance or support or supervision or review of their practice.
This seems odd.
Is it just in my corner that life's like this?
Friday, 4 April 2008
Thursday, 3 April 2008
Vascular Dementia
I've seen a young lady with vascular dementia. I thought it was F01.0 Vascular dementia in acute onset but on sleuthing it out over the last few weeks it seems it's in fact F01.1 Multi-infract dementia. I was interested 'cause I like to know (but not in such a psychopathic Gregory House sort of way) but also if it is acute then clever physicians could try and sort out why.
But this difference largely is irrelevant.
She has vascular dementia.
It's pretty classical. She has very well preserved "islands of ability" meaning some things are completely perfect. She can recognise faces and people, she can sequence tasks, she's good concentration, she's got mildly impaired memory, she's got only mild disorientation. She's no dyspraxia. She can manage buttons on her blouse, she managed her espresso coffee machine that looked as complex as the dashboard of the space shuttle, she managed to use fiddly buttons on her mobile 'phone to text a friend.
She has profound nominal aphasia. She knows what she wants/means, she just can't connect with what the word for that is. She was able to tell me she wanted "that thing" to stir a coffee but simply couldn't generate the word "teaspoon" at all.
This has had a significant impact on her, socially. She's stopped meeting friends, no longer enjoys her walks around the village to the bookshop and back, she's stopped having lunch in the local cafe every Tuesday "with the girls" as she used to, she's stopped going to antique/second hand shops and browsing for a certain type of pottery she likes to collect. Why? She's too self conscious that she can't speak fluidly any more.
She's bright, animated, intelligent, active and oh so very aware. But she's locked in. She's a massively constrained social repetoire as a consequence of her impaired expressive aphasia.
But this difference largely is irrelevant.
She has vascular dementia.
It's pretty classical. She has very well preserved "islands of ability" meaning some things are completely perfect. She can recognise faces and people, she can sequence tasks, she's good concentration, she's got mildly impaired memory, she's got only mild disorientation. She's no dyspraxia. She can manage buttons on her blouse, she managed her espresso coffee machine that looked as complex as the dashboard of the space shuttle, she managed to use fiddly buttons on her mobile 'phone to text a friend.
She has profound nominal aphasia. She knows what she wants/means, she just can't connect with what the word for that is. She was able to tell me she wanted "that thing" to stir a coffee but simply couldn't generate the word "teaspoon" at all.
This has had a significant impact on her, socially. She's stopped meeting friends, no longer enjoys her walks around the village to the bookshop and back, she's stopped having lunch in the local cafe every Tuesday "with the girls" as she used to, she's stopped going to antique/second hand shops and browsing for a certain type of pottery she likes to collect. Why? She's too self conscious that she can't speak fluidly any more.
She's bright, animated, intelligent, active and oh so very aware. But she's locked in. She's a massively constrained social repetoire as a consequence of her impaired expressive aphasia.
Tuesday, 1 April 2008
Communication
Shamelessly nicking more themes from more inventive folks blogs, I happily found Hospital Wallpaper's medical student blog after she commented below. She wrote about communication skills and wondered :
"Can communications skills be learnt or are they inherent in a person's character?"
I don't think it's that black or white a nature/nurture thing. If someone's inherently good at it, that's great. But I know medics with a brain the size of Saturn who really are great at diagnosis and therapy but were bad communicators who have improved lots. Experience in medicine, maturity, training can help.
What helps me improve more than anything is what Hospital Wallpaper did. She sat in and saw a clinician communicate. You learn what they do well, and nick that, and what they could do better, so learn to do it differently.
Every week I go on joint visits with nursing colleagues, every week I'm aware of little things they do better than I do, that I nick in my approach to consultations.
"Can communications skills be learnt or are they inherent in a person's character?"
I don't think it's that black or white a nature/nurture thing. If someone's inherently good at it, that's great. But I know medics with a brain the size of Saturn who really are great at diagnosis and therapy but were bad communicators who have improved lots. Experience in medicine, maturity, training can help.
What helps me improve more than anything is what Hospital Wallpaper did. She sat in and saw a clinician communicate. You learn what they do well, and nick that, and what they could do better, so learn to do it differently.
Every week I go on joint visits with nursing colleagues, every week I'm aware of little things they do better than I do, that I nick in my approach to consultations.
Monday, 31 March 2008
Interesting lives
This morning I spoke with folk and, as usual, was struck by the rich tapestry of life.
One patient has had a fascinating career working in bomb disposal. Not a vocation for the faint hearted.
One patient has an engaging and encyclopaedic knowledge of greyhounds. Breeding, racing, everything.
One patient knows incredible amounts about tapestry and needlework. She returned from France where she travelled, alone, to visit a convent where some nuns could teach her a particular style and stitch.
People have such interesting lives, some days you're shaken in to realising it's a real privilege to share this.
One patient has had a fascinating career working in bomb disposal. Not a vocation for the faint hearted.
One patient has an engaging and encyclopaedic knowledge of greyhounds. Breeding, racing, everything.
One patient knows incredible amounts about tapestry and needlework. She returned from France where she travelled, alone, to visit a convent where some nuns could teach her a particular style and stitch.
People have such interesting lives, some days you're shaken in to realising it's a real privilege to share this.
Saturday, 22 March 2008
Diazepam
Over the last month two GPs have referred their patients to me "on diazepam" for their anxiety.
Both ladies have been on diazepam for anxiety for decades.
Both ladies had stable mental health on diazepam, with no panic attacks, no reduction of Activities of Daily Living or constricted behavioural repetoire, no altered symptoms or presentation, no distress.
Both ladies had no side effects on their diazepam.
Both ladies had the option of other ways of coping presented to them, neither sought to do so. Whatever I suggested was politely declined, they were quite happy staying on their diazepam, thank you kindly.
Both ladies were averaging diazepam 2mg twice a day. Neither was getting more, I went through their boxes of tablets at their homes, counted how many they'd got, counted when they were dispensed, knew when the repeat prescriptions were due and it all matched up. Compliance with prescribed medication was spot on.
Both ladies had a diagnosis of "anxiety" made decades ago on what, to me, seemed somewhat spurious grounds. But I accept that medical notes are just notes, so the true situation isn't always well captured. Both ladies were started on diazepam, it worked, nobody's revisited the diagnosis or treatment and they've remained on it for decades.
Both ladies believe their diazepam does them good, keeps them well, causes no problems and they're both desperately keen to continue on it. Both felt that without out it they'd "be terrible" and become very unwell very quickly. Doctors have said so, which is why they take their medication so meticulously. Both truly believe they've a need for this medication. Both firmly believe this medication is powerfully potent in maintaining their wellbeing thus without it they believe, with great certainty, that they'll be vastly worse.
Tricky one, this. If it was 5mg of diazepam four times a day I'd have issues with it, but 2mg bd is a very modest dose. Pharmacologically, it's a dose you don't get hooked on. So they're not chemically dependent on the benzodiazepine and, in fact, it could be stopped. Psychologically they're both strongly wedded to the notion that diazepam = health and no diazepam = illness. Decades of experiential learning ahs proved this to them, they've continued on diazepam and been well, so there you go, it has to work.
Neither wanted help in anxiety management (not having been anxious for decades). Neither really knew why they had to see me at all. Having discussed options we all agreed there wasn't any need for them to see me again, but I'd be happy to do so if they wanted to. They left with open appointments, so can book in to see me without a referral, and I wrote back to their GPs saying that all seemed well. Both GPs were happy with things being reviewed and the decision being to continue.
Does make me wonder, though, whether medication of dubious benefit should be continued, even if it's safe and cheap and seemingly effective, just to please the patient and make life easier for medics. Because, objectively, there's no reason for the medication to be continued and a drug free trial makes good pharmacological sense.
Of course, the two ladies would resist this vociferously, but they can't prescribe so the decision's ultimately not theirs to take.
Turning a blind eye to diazepam 2mg bd, is that acceptable or is that an anthema to Evidence Based Medicine and the thin end of the wedge of poor practice?
Both ladies have been on diazepam for anxiety for decades.
Both ladies had stable mental health on diazepam, with no panic attacks, no reduction of Activities of Daily Living or constricted behavioural repetoire, no altered symptoms or presentation, no distress.
Both ladies had no side effects on their diazepam.
Both ladies had the option of other ways of coping presented to them, neither sought to do so. Whatever I suggested was politely declined, they were quite happy staying on their diazepam, thank you kindly.
Both ladies were averaging diazepam 2mg twice a day. Neither was getting more, I went through their boxes of tablets at their homes, counted how many they'd got, counted when they were dispensed, knew when the repeat prescriptions were due and it all matched up. Compliance with prescribed medication was spot on.
Both ladies had a diagnosis of "anxiety" made decades ago on what, to me, seemed somewhat spurious grounds. But I accept that medical notes are just notes, so the true situation isn't always well captured. Both ladies were started on diazepam, it worked, nobody's revisited the diagnosis or treatment and they've remained on it for decades.
Both ladies believe their diazepam does them good, keeps them well, causes no problems and they're both desperately keen to continue on it. Both felt that without out it they'd "be terrible" and become very unwell very quickly. Doctors have said so, which is why they take their medication so meticulously. Both truly believe they've a need for this medication. Both firmly believe this medication is powerfully potent in maintaining their wellbeing thus without it they believe, with great certainty, that they'll be vastly worse.
Tricky one, this. If it was 5mg of diazepam four times a day I'd have issues with it, but 2mg bd is a very modest dose. Pharmacologically, it's a dose you don't get hooked on. So they're not chemically dependent on the benzodiazepine and, in fact, it could be stopped. Psychologically they're both strongly wedded to the notion that diazepam = health and no diazepam = illness. Decades of experiential learning ahs proved this to them, they've continued on diazepam and been well, so there you go, it has to work.
Neither wanted help in anxiety management (not having been anxious for decades). Neither really knew why they had to see me at all. Having discussed options we all agreed there wasn't any need for them to see me again, but I'd be happy to do so if they wanted to. They left with open appointments, so can book in to see me without a referral, and I wrote back to their GPs saying that all seemed well. Both GPs were happy with things being reviewed and the decision being to continue.
Does make me wonder, though, whether medication of dubious benefit should be continued, even if it's safe and cheap and seemingly effective, just to please the patient and make life easier for medics. Because, objectively, there's no reason for the medication to be continued and a drug free trial makes good pharmacological sense.
Of course, the two ladies would resist this vociferously, but they can't prescribe so the decision's ultimately not theirs to take.
Turning a blind eye to diazepam 2mg bd, is that acceptable or is that an anthema to Evidence Based Medicine and the thin end of the wedge of poor practice?
Monday, 10 March 2008
GPs
I met with a GP rather early (because most GPs in my neighbourhood start work at some ungodly hour) to look at the care of a gentleman with dementia. If you're one for diagnostic labels, he's got F00.12 Dementia in Alzheimer's disease, late onset, severe.
On first appearences, he's muddled but manageable. He's not leaving the house, not posing risks to others outside, not wandering in front of traffic, he's fed and watered and cared for by his wife. Speaking with him he says all's fine and can't understand why my nurses and I visit him, or why we dragged his GP there on this occasion.
The truth of it is that the cost of keeping him at home is high. Arguably too high. His wife is going under, big time. He's disoriented so seeks reassaurance. All the time. Really, all the time, such that he follows her everywhere, even to the toilet. She's scared since at night he comes to shout at her, distraught, so she's had to buy a lock for her bedroom door. Her reassaurance doesn't work now, he just gets frustrated and angry and can't understand why things aren't as he recalls/believes they should be.
She's in floods of tears most of the day. She's not clinically depressed, she's just in an untenable situation where she's no longer valued or respected but, despite endless devotion, is shouted at and abused. She gets almost no sleep.
We know this because we visit her and I've been seeing her and her husband for some 4 years now. Their GP knows because I keep in touch with her and she visits them, mostly to support the wife. We're supporting his wife in letting go and choosing a care home for him.
When the government finishes shafting GPs and we've polyclinics in Tescos instead, will the medic or nurse practitioner see this couple at home over time, too? Will they do home visits at all? If they do visit him at home, not having met him or known him before, would they just take at face value what is seen or would they spend an hour unpicking it all then work with me and visit over time to see the system as a whole (physical health, mental health, disturbed behaviour, care for him, cost to the wife) or would they focus just on their patient? Focussing just on their patient, the wife would go under, he'd be placed in emergency respite care (so would be in a care home neither he nor his wife chose) and she'd feel tremendous guilt at having failed.
I've feelings of disquiet . . .
On first appearences, he's muddled but manageable. He's not leaving the house, not posing risks to others outside, not wandering in front of traffic, he's fed and watered and cared for by his wife. Speaking with him he says all's fine and can't understand why my nurses and I visit him, or why we dragged his GP there on this occasion.
The truth of it is that the cost of keeping him at home is high. Arguably too high. His wife is going under, big time. He's disoriented so seeks reassaurance. All the time. Really, all the time, such that he follows her everywhere, even to the toilet. She's scared since at night he comes to shout at her, distraught, so she's had to buy a lock for her bedroom door. Her reassaurance doesn't work now, he just gets frustrated and angry and can't understand why things aren't as he recalls/believes they should be.
She's in floods of tears most of the day. She's not clinically depressed, she's just in an untenable situation where she's no longer valued or respected but, despite endless devotion, is shouted at and abused. She gets almost no sleep.
We know this because we visit her and I've been seeing her and her husband for some 4 years now. Their GP knows because I keep in touch with her and she visits them, mostly to support the wife. We're supporting his wife in letting go and choosing a care home for him.
When the government finishes shafting GPs and we've polyclinics in Tescos instead, will the medic or nurse practitioner see this couple at home over time, too? Will they do home visits at all? If they do visit him at home, not having met him or known him before, would they just take at face value what is seen or would they spend an hour unpicking it all then work with me and visit over time to see the system as a whole (physical health, mental health, disturbed behaviour, care for him, cost to the wife) or would they focus just on their patient? Focussing just on their patient, the wife would go under, he'd be placed in emergency respite care (so would be in a care home neither he nor his wife chose) and she'd feel tremendous guilt at having failed.
I've feelings of disquiet . . .
Thursday, 6 March 2008
Humble Pie
I am sceptical about the benefits of aromatherapy. I am not anti-complimentary therapy. Just as I am sceptical about the benefits of some drugs, the effect of some injections and the validity of a lot of cardiac surgery, so I am sceptical about aromatherapy.
You smell stuff and get better. Huh?
Some sites are nauseating in their juxtaposition of soft fluffy cuddly safeness and hard longterm pseudoscience. Would you trust this salesman? I wouldn't. Some content just riles me too much.
Several of our band 3 and band 4 staff have undertaken aromatherapy and massage courses. They've been undertaking aromatherapy and hand massage with patients who have dementia. A proportion of patients have behavioural and psychological symptoms of dementia (BPSD). As they're increasingly distraught and disoriented they find it harder to engage with the nursing staff. Confrontational and unhelpful behaviour can escalate. Medication is used to help them regain control to engage in the reality orientation processes with nursing staff. This gives me audit data showing the prevalence of lorazepam use prn (as needed) for BPSD on that day unit.
Staff didn't change. The band 3 and band 4 staff started to do aromatherapy hand massages and burn basil and whatnots. Incidence of BPSD reduced. Prevalence of lorazepam use prn reduced.
Maybe it does work on the limbic system, improving things for a wee while. Maybe it's a placebo effect. I don't know. But it seems to be useful for some of my patients, some of the time, with no significant treatment emergent adverse events.
You smell stuff and get better. Huh?
Some sites are nauseating in their juxtaposition of soft fluffy cuddly safeness and hard longterm pseudoscience. Would you trust this salesman? I wouldn't. Some content just riles me too much.
Several of our band 3 and band 4 staff have undertaken aromatherapy and massage courses. They've been undertaking aromatherapy and hand massage with patients who have dementia. A proportion of patients have behavioural and psychological symptoms of dementia (BPSD). As they're increasingly distraught and disoriented they find it harder to engage with the nursing staff. Confrontational and unhelpful behaviour can escalate. Medication is used to help them regain control to engage in the reality orientation processes with nursing staff. This gives me audit data showing the prevalence of lorazepam use prn (as needed) for BPSD on that day unit.
Staff didn't change. The band 3 and band 4 staff started to do aromatherapy hand massages and burn basil and whatnots. Incidence of BPSD reduced. Prevalence of lorazepam use prn reduced.
Maybe it does work on the limbic system, improving things for a wee while. Maybe it's a placebo effect. I don't know. But it seems to be useful for some of my patients, some of the time, with no significant treatment emergent adverse events.
Wednesday, 5 March 2008
Approved Clinicians
The new Mental Health Act legislation makes for interesting reading, to folk working in mental health. It allows nurses (and others) to hold Approved Clinician (AC) status. Being an AC means they can be the Responsible Clinician (RC) for a detained patient, instead of a psychiatrist being the Responsible Medical Officer (RMO). Most psychiatrists will have AC status so can still be RCs come October, but not all psychiatrists will automatically convert to having AC status. The change opens up the option of nurse lead units where psychiatrists have a much more modest role and aren't directly either involved or responsible for detained patients' care.
Tainted Halo asked, "I'm very interested to see how doctors embrace this new world freedom?! . . . what do the learned shrinks think they'll do with it?"
In my corner, we're having none of it.
Why?
Well, frankly, we're in the happy position of not needing to. Looking after detained in-patients isn't an onerous duty for us. We're in an urban setting so have benefits of covering a relatively small, tight geographical patch. We've easy access to psychiatrists, section 12 approved doctors and Approved Social Workers. We've frequent review of patients on the ward which is multidisciplinary. The reviews are frequent so they can be small (i.e. just a couple of people meet with the patient each time, rather than a room full of folk to face). As such there's frequent (daily to weekly weekly) input from medical, nursing, occupational therapy, pharmacist, social work and physiotherapy staff.
Recent presentations by CSIP and the DoH explained that change wasn't necessary in units such as ours. Fantastic to hear that for once central agencies aren't advocating change for changes sake.
Since we're able to have our cake and eat it, offering detained patients input from a wide range of professionals all working together, all seems well. The Healthcare Commission have been very happy with our mode and standards of care. We've not had issues from the MHAC either, who are oh so very rigorous. Since our patients, commissioners, carers, Healthcare Commission and MHAC are happy with what we're providing, as are we, we're able to say we've considered other service models but for now ours addresses patients' needs.
If it ain't broke, don't fix it.
Tainted Halo asked, "I'm very interested to see how doctors embrace this new world freedom?! . . . what do the learned shrinks think they'll do with it?"
In my corner, we're having none of it.
Why?
Well, frankly, we're in the happy position of not needing to. Looking after detained in-patients isn't an onerous duty for us. We're in an urban setting so have benefits of covering a relatively small, tight geographical patch. We've easy access to psychiatrists, section 12 approved doctors and Approved Social Workers. We've frequent review of patients on the ward which is multidisciplinary. The reviews are frequent so they can be small (i.e. just a couple of people meet with the patient each time, rather than a room full of folk to face). As such there's frequent (daily to weekly weekly) input from medical, nursing, occupational therapy, pharmacist, social work and physiotherapy staff.
Recent presentations by CSIP and the DoH explained that change wasn't necessary in units such as ours. Fantastic to hear that for once central agencies aren't advocating change for changes sake.
Since we're able to have our cake and eat it, offering detained patients input from a wide range of professionals all working together, all seems well. The Healthcare Commission have been very happy with our mode and standards of care. We've not had issues from the MHAC either, who are oh so very rigorous. Since our patients, commissioners, carers, Healthcare Commission and MHAC are happy with what we're providing, as are we, we're able to say we've considered other service models but for now ours addresses patients' needs.
If it ain't broke, don't fix it.
Thursday, 28 February 2008
Mental Health Act 2007
Parts of the new Mental Health Act 2007 are already with us but most of it comes in to force this October. It's a smaller bit of legislation than the original Act, so it will still be known as the Mental Health Act 1983 (MHA 1983) but this new bit of law ammends some key areas.
Some are widely known. No longer will doctors have to look after detained patients, the Responsible Medical Officer (RMO) role ceases to exist and instead we have Approved Clinicians (who could be nurses, psychologists, occupation therapists etc) who can then act as the Responsible Clinician instead of a psychiatrist. So when detained under section 3, it could be almost anyone looking after you and deciding when you are allowed out, with psychiatrists nowhere to be seen.
Interesting times, eh?
The implications of some changes are less well known. It was, oddly, a carers forum that developed this scenario at me. I then spoke with a lawyer :
A patient, Alex, becomes unwell after drinking alcohol and using cannabis and becomes psychotic. He stops work and is admitted under the MHA 1983 for 6 weeks, having a period of time being detained in hospital for treatment under section 3.
After 6 weeks in hospital he's back home again with his family.
2 weeks after this he's back at work.
Alex then drinks alcohol and use cannabis.
He become psychotic and is admitted, again.
His family are cross that he's psychotic again, why did we let this happen?
This pattern repeats itself over time.
Summary : A patient has serious psychotic episodes as a result of lifestyle choices they elect to make.
Implications : We've detained him under section 3 of the MHA 1983 and have a duty of care. Her Majesty's Government has given us an instrument to provide care for him, in the form of the MHA 1983. From October this year, this extends to Supervised Community Treatment (SCT) that has to be considered for all patients detained under section 3 (and other treatment sections). We have to consider this (as in, the law says so, and when we have to, e.g. when you have more than 7 days leave, so it can't be ignored).
If Alex uses alcohol and cannabis, he becomes psychotic. If Alex doesn't, he doesn't. When we look after him, we are attempting to get him well and keep him well (with advice, psychological therapy, medication, support, whatever). We have to, it's our duty of care for a detained patient (and continues to be our duty through section 117, SCT and under the Care Programme Approach). Some sections (7, 25) specifically require more.
How do we exercise our duty to look after Alex and avert psychosis (with the loss of income, distress to him and his family, time out in hospital and so on) when he's discharged from hospital?
We use a SCT that requires he abstains. We say he has to abstain, since to do otherwise is to cause a relapse. Just the way he could be told he has to take his tablets, family/carers were adamant that mental health services should be directing patients who become psychotic on drugs not to take drugs. Under a SCT what happens if they fail to take their tablets or fail to abstain from cannabis? They're recalled back to hospital by their Responsible Clinician, RC (who could be a CPN, ward nurse, psychologist, OT, whoever). After a couple days and an AMHP (from October what an approved social worker will be) a section 3 starts again (note, no medical recommendation has been made for this and they're there for up to 6 months, now).
The stick : abstain from alcohol and drugs, take your tablets, or you're locked up. Again.
The pressure from carers and family : how can the Responsible Clinician not do this? The RC has a duty of care to Alex. The RC knows if Alex uses alcohol/drugs he becomes psychotic so to support community placement Alex must avoid them. The government's given us a tool to effect this care plan and ensure Alex remains well. To not use a SCT, thus allowing him to become psychotic (which is a forseeable event we can reasonably predict) can be seen as a failure of the RC in their duty of care to Alex and as medical negligence. The family can complain that the RC was able to avert this psychotic episode through use of the SCT but didn't, thus a letter from Bastard, Bugger and Brown Solicitors is on it's way to the Trust to sue their asses for an episode of psychosis that was forseeable and could have been prevented if the RC had used an SCT appropriately.
Mental health services enforcing such things, and there are oh so many things that impact 'pon mental wellbeing that we could enforce . . .
. . . may we live in interesting times.
Some are widely known. No longer will doctors have to look after detained patients, the Responsible Medical Officer (RMO) role ceases to exist and instead we have Approved Clinicians (who could be nurses, psychologists, occupation therapists etc) who can then act as the Responsible Clinician instead of a psychiatrist. So when detained under section 3, it could be almost anyone looking after you and deciding when you are allowed out, with psychiatrists nowhere to be seen.
Interesting times, eh?
The implications of some changes are less well known. It was, oddly, a carers forum that developed this scenario at me. I then spoke with a lawyer :
A patient, Alex, becomes unwell after drinking alcohol and using cannabis and becomes psychotic. He stops work and is admitted under the MHA 1983 for 6 weeks, having a period of time being detained in hospital for treatment under section 3.
After 6 weeks in hospital he's back home again with his family.
2 weeks after this he's back at work.
Alex then drinks alcohol and use cannabis.
He become psychotic and is admitted, again.
His family are cross that he's psychotic again, why did we let this happen?
This pattern repeats itself over time.
Summary : A patient has serious psychotic episodes as a result of lifestyle choices they elect to make.
Implications : We've detained him under section 3 of the MHA 1983 and have a duty of care. Her Majesty's Government has given us an instrument to provide care for him, in the form of the MHA 1983. From October this year, this extends to Supervised Community Treatment (SCT) that has to be considered for all patients detained under section 3 (and other treatment sections). We have to consider this (as in, the law says so, and when we have to, e.g. when you have more than 7 days leave, so it can't be ignored).
If Alex uses alcohol and cannabis, he becomes psychotic. If Alex doesn't, he doesn't. When we look after him, we are attempting to get him well and keep him well (with advice, psychological therapy, medication, support, whatever). We have to, it's our duty of care for a detained patient (and continues to be our duty through section 117, SCT and under the Care Programme Approach). Some sections (7, 25) specifically require more.
How do we exercise our duty to look after Alex and avert psychosis (with the loss of income, distress to him and his family, time out in hospital and so on) when he's discharged from hospital?
We use a SCT that requires he abstains. We say he has to abstain, since to do otherwise is to cause a relapse. Just the way he could be told he has to take his tablets, family/carers were adamant that mental health services should be directing patients who become psychotic on drugs not to take drugs. Under a SCT what happens if they fail to take their tablets or fail to abstain from cannabis? They're recalled back to hospital by their Responsible Clinician, RC (who could be a CPN, ward nurse, psychologist, OT, whoever). After a couple days and an AMHP (from October what an approved social worker will be) a section 3 starts again (note, no medical recommendation has been made for this and they're there for up to 6 months, now).
The stick : abstain from alcohol and drugs, take your tablets, or you're locked up. Again.
The pressure from carers and family : how can the Responsible Clinician not do this? The RC has a duty of care to Alex. The RC knows if Alex uses alcohol/drugs he becomes psychotic so to support community placement Alex must avoid them. The government's given us a tool to effect this care plan and ensure Alex remains well. To not use a SCT, thus allowing him to become psychotic (which is a forseeable event we can reasonably predict) can be seen as a failure of the RC in their duty of care to Alex and as medical negligence. The family can complain that the RC was able to avert this psychotic episode through use of the SCT but didn't, thus a letter from Bastard, Bugger and Brown Solicitors is on it's way to the Trust to sue their asses for an episode of psychosis that was forseeable and could have been prevented if the RC had used an SCT appropriately.
Mental health services enforcing such things, and there are oh so many things that impact 'pon mental wellbeing that we could enforce . . .
. . . may we live in interesting times.
Wednesday, 27 February 2008
Responsibility
An argument made by a patient's mother to me (who couldn't grasp what her son said his schizophrenia was about) went like this :
If I was to stand next to you at a bus stop, point out some random person across the street who was wearing red and say, "They have to die. They have to die!" you'd be wary. If I then said, "Go and stab them! Go on, now, quickly, go and stab them!" you'd probably pull out your mobile 'phone and call the police who'd want a chat about why I was making threats to kill, which they take seriously.
Presumably you'd also ignore me, rather than stabbing up some poor soul simply because I told you to.
The mother's point was that this is what her son experiences; he has auditory hallucinations both giving comment and imperative commands. Crucially, he doesn't have delusional beliefs or delusional perception (and in fact I'm unsure how robust the diagnosis of schizophrenia is since he just hears voices). She just couldn't see why it was any different hearing them as voices compared to hearing her say something he'd normally find ridiculous and discount. She felt he should be able to treat the voices just the same way he'd treat some random meaningless stranger, "who's chirping away with rubbish!"
I don't wholly agree with her, but she got me thinking. Without delusions or cognitive distortions, as a capacitated adult (passing the MCA 2005 test), is he totally responsible for all he does? She believes he is. Courts consistently have not.
If I was to stand next to you at a bus stop, point out some random person across the street who was wearing red and say, "They have to die. They have to die!" you'd be wary. If I then said, "Go and stab them! Go on, now, quickly, go and stab them!" you'd probably pull out your mobile 'phone and call the police who'd want a chat about why I was making threats to kill, which they take seriously.
Presumably you'd also ignore me, rather than stabbing up some poor soul simply because I told you to.
The mother's point was that this is what her son experiences; he has auditory hallucinations both giving comment and imperative commands. Crucially, he doesn't have delusional beliefs or delusional perception (and in fact I'm unsure how robust the diagnosis of schizophrenia is since he just hears voices). She just couldn't see why it was any different hearing them as voices compared to hearing her say something he'd normally find ridiculous and discount. She felt he should be able to treat the voices just the same way he'd treat some random meaningless stranger, "who's chirping away with rubbish!"
I don't wholly agree with her, but she got me thinking. Without delusions or cognitive distortions, as a capacitated adult (passing the MCA 2005 test), is he totally responsible for all he does? She believes he is. Courts consistently have not.
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