I've been seeing a patient for some time, withdrawing their benzodiazepines with them. Mentally well all his life, the patient had felt anxious and when he retired, then widowed, had declined talking therapies and sought medication to help. His GP is a sensible soul but over time and by accident and through locums whilst on holiday ended up with a patient being prescribed and taking very hefty doses of two benzodiazepines and wanting more.
The drugs weren't working any more. On mornings and after coming down off the drugs' peak effects, he was restless and irritable and more anxious. He'd started falling. Alcohol intake was modest (a couple glasses of wine a week) with normal liver function.
I had never seen the patient before being involved this time. I had not started the benzodiazepines. Our PCT has commissioned neither drug and alcohol services nor my corner to manage iatrogenic addiction (ie the doctor caused it), feeling if one doctor's caused dependence through their prescribing, they need to sort it out. I'm no expert at substance misuse at all. The patient had no wish to see me to reduce benzodiazepines, quite the opposite, he wanted more.
I've massive sympathy for the patient and for the GP. Both were trying to do their best at the original point in time, managing the few poor choices they felt were laid out before them. The GP wrote an excellent detailed helpful referral letter to me, asking if I could sort it all out. She's a good GP. She's helpful. We both collude in working to do what's best for her patients despite the local policies and care pathways and frameworks and shared care arrangements; she's sensible in ignorning most of the bureaucracy and instead we just crack on with what's best. I might prescribe when it should sit within her budget. She might prescribe when it hasn't been the exact blah months needed for a shared care to start. She's a good clinician and she works hard, very hard, to support her patients as best she can.
When she wrote saying she'd messed up and got herself into a tricky position, she knew I wasn't a drug and alcohol expert, but she felt stuck and uneasy, well as said within Jerry Maguire she had me at "hello" and I couldn't leave her to flounder.
The patient loves his GP, thinks his GP is ace. I've been involved for many months and soon will be discharging the patient, benzodiazepine free. The patient suffers my visits and has a less than favourable view of what I've done. He understands why, but it's not what he wanted. But as he 'fesses up, he was addicted. I won't need to see him again, hopefully. His GP hopefully will be seeing him for many years.
Even if it's not my mess, not my work, not my problem, sometimes it's better for the GP to be the good guy and me to be the bad guy.
I wonder if the new NHS commissioning and structures will facilitate helpful working arrangement . . .
Saturday, 19 March 2011
Monday, 14 March 2011
Blame
A banker, a Daily Mail reader and a Benefit Claimant are sat round a table, and there are 12 biscuits.
The banker immediately takes 11 and whispers to the Daily Mail reader, "Be careful, that Benefit Claimant is after your biscuit."
The banker immediately takes 11 and whispers to the Daily Mail reader, "Be careful, that Benefit Claimant is after your biscuit."
Wednesday, 9 March 2011
Policy is a direction and framework we consider (and should strongly consider) in deciding our clinical practice.
But policy supports clinical practice. Clinical practice doesn't support policy. We do what's right, we don't do what's written down. That's why qualified staff take clinical decisions instead of unqualified staff delivering what the policy says with no decison making at all.
Pyjamas in Bananas has pointed out the flaws of trying to support and use policy documents.
Part of me, rather impishly, wonders how much I should follow policy guidance. NICE guidance should apply to about 3/4 of the population the guidance is generated for. The routine, standard care should typically be in accord with NICE guidance, but for 1/4 of patients specific bespoke custom care is likely to be more appropriate.
As a specialist within Secondary Care services, I'm seeing a patient population that almost by definition don't fit typical routine care pathways that GP and non-medical mental health colleagues progress. When something's unusual or complex, that's typically when it's brought to my door.
On that basis, if NICE guidance applies to 75% of patients, and over 75% are managed in Primary Care or within NICE guidance by nurse lead services in Secondary Care, I'm seeing a portion of all the remaining 25% who sit outside NICE guidance.
Shouldn't 100% of my workload by complex/atypical stuff meaning I'm never adhering to standard policy or guidance or protocol? As I said, it's an impish thought, but I have shared with my Chief Exec that I fear I'm far too compliant with guidance and need to be more maveric and eschew such constraints on my clinical freedom, nigh on 100% of the time. Food for thought . . .
But policy supports clinical practice. Clinical practice doesn't support policy. We do what's right, we don't do what's written down. That's why qualified staff take clinical decisions instead of unqualified staff delivering what the policy says with no decison making at all.
Pyjamas in Bananas has pointed out the flaws of trying to support and use policy documents.
Part of me, rather impishly, wonders how much I should follow policy guidance. NICE guidance should apply to about 3/4 of the population the guidance is generated for. The routine, standard care should typically be in accord with NICE guidance, but for 1/4 of patients specific bespoke custom care is likely to be more appropriate.
As a specialist within Secondary Care services, I'm seeing a patient population that almost by definition don't fit typical routine care pathways that GP and non-medical mental health colleagues progress. When something's unusual or complex, that's typically when it's brought to my door.
On that basis, if NICE guidance applies to 75% of patients, and over 75% are managed in Primary Care or within NICE guidance by nurse lead services in Secondary Care, I'm seeing a portion of all the remaining 25% who sit outside NICE guidance.
Shouldn't 100% of my workload by complex/atypical stuff meaning I'm never adhering to standard policy or guidance or protocol? As I said, it's an impish thought, but I have shared with my Chief Exec that I fear I'm far too compliant with guidance and need to be more maveric and eschew such constraints on my clinical freedom, nigh on 100% of the time. Food for thought . . .
Thursday, 3 March 2011
Case Based Discussion
We tell patients the truth. How much is valid consent, how much is coercion?
This is a theme that case based discussion threw up with my colleagues and me. I was pleased, I'd not expected case based discussion to be at all useful. On exploring, with a peer group, how a Consultant managed random in-patient episodes, reviewing the notes and talking it through, a significant difference in approach emerged.
One school of thought was that patients deserve the truth, patients need an honest account of what professional advice a Consultant is offering. More, patients also need to know the consequences of their choice, if it's to be making a considered and valid decision, so patients need to be aware of outcomes from choices. Consultants in this camp will tell patients something along the lines, "We're both agreeing that you're not as well as we'd both wish, we're seeing you're behaving in a way that's unhelpful to you and those you care about, we know being in hospital is helpful for you and over a few weeks has worked every time before, I strongly believe you need to be in hospital, now."
The patient declines the offer of support within an in-patient unit and then is told, "If you're not wishing to come in informally, I'll need to look at a Mental Health Act assessment and admission under section 2."
It was strongly argued that not to tell the patient this was unfair, since valid consent and joint guidance from the BMA and Law Society in 2004 requires that the patient needed to know the consequences of not accepting the proposed treatment.
The other school of thought was that patients deserve the truth and an honest account but this related to the immediate issue. Whether their choices could then perhaps lead to discharge or perhaps to compulsory admission or maybe to consideration of a depot or whatever is a future consideration and shouldn't excessively influence the decision in the here and now.
It was suggested you'd have the same identical conversation but if after you recommended hospital admission your patient declines, you'd walk away and discuss it with the MDT and an AMHP rather than suggest compulsory denention.
It was strongly argued that as well as essentially making a threat, however tactfully delivered, it was inappropriate to offer informal admission then in the same breath say that if you don't come informally, formal admission will be sought, because there's then undue pressure. The same joint guidance from the BMA and Law Society in 2004 reequire that valid consent is made with "free choice" to curtailing choice to "do this, or I'll make it happen" is a less than free choice.
Mostly the argumements and points of view expressed by the Consultants weren't medicolegal or clinical, but essentially were ethical.
Is it better to be totally honest and let patients know the consequences of their decisions? Is it better to offer the choice and then if patients choose to decline, to then approach the MDT/AMHP to discount informal admission and revisit options?
I was firmly in the second camp, I've never to my recollection said to a patient that I'm offering informal admission and if it's declined I'm coming back with pink papers, an AMHP, a GP and an ambulance (with or without police, to convey) since that to my mind could be perceived as somewhat coercive. The argument was that I'd then be admitting people under a section of the MHA 1983 more often than they otherwise needed to be. I typically have just a couple of section 2 admissions a year, I've only made recommendations and managed my patients under section 3 twice in my career to date, so my use of both section 2 and section 3 is lower than colleagues within my peer group.
Different points of view, with different Consultants giving different answers. Usually you ask half a dozen Consultant Psychiatrists a question and you get half a dozen different answers. Unusually we had agreement with just 2 camps and recognition that the opposing camp had valid views but maintaining strong views that their camp was the best way to practice.
I was surprised by how useful the case based discussion was. I'd expected a tedious hour. The open exploration of implications of different approaches to practice, reflection on how we worked and discussion of alternate view points was stimulating and genuinely useful.
A pleasant surprise.
This is a theme that case based discussion threw up with my colleagues and me. I was pleased, I'd not expected case based discussion to be at all useful. On exploring, with a peer group, how a Consultant managed random in-patient episodes, reviewing the notes and talking it through, a significant difference in approach emerged.
One school of thought was that patients deserve the truth, patients need an honest account of what professional advice a Consultant is offering. More, patients also need to know the consequences of their choice, if it's to be making a considered and valid decision, so patients need to be aware of outcomes from choices. Consultants in this camp will tell patients something along the lines, "We're both agreeing that you're not as well as we'd both wish, we're seeing you're behaving in a way that's unhelpful to you and those you care about, we know being in hospital is helpful for you and over a few weeks has worked every time before, I strongly believe you need to be in hospital, now."
The patient declines the offer of support within an in-patient unit and then is told, "If you're not wishing to come in informally, I'll need to look at a Mental Health Act assessment and admission under section 2."
It was strongly argued that not to tell the patient this was unfair, since valid consent and joint guidance from the BMA and Law Society in 2004 requires that the patient needed to know the consequences of not accepting the proposed treatment.
The other school of thought was that patients deserve the truth and an honest account but this related to the immediate issue. Whether their choices could then perhaps lead to discharge or perhaps to compulsory admission or maybe to consideration of a depot or whatever is a future consideration and shouldn't excessively influence the decision in the here and now.
It was suggested you'd have the same identical conversation but if after you recommended hospital admission your patient declines, you'd walk away and discuss it with the MDT and an AMHP rather than suggest compulsory denention.
It was strongly argued that as well as essentially making a threat, however tactfully delivered, it was inappropriate to offer informal admission then in the same breath say that if you don't come informally, formal admission will be sought, because there's then undue pressure. The same joint guidance from the BMA and Law Society in 2004 reequire that valid consent is made with "free choice" to curtailing choice to "do this, or I'll make it happen" is a less than free choice.
Mostly the argumements and points of view expressed by the Consultants weren't medicolegal or clinical, but essentially were ethical.
Is it better to be totally honest and let patients know the consequences of their decisions? Is it better to offer the choice and then if patients choose to decline, to then approach the MDT/AMHP to discount informal admission and revisit options?
I was firmly in the second camp, I've never to my recollection said to a patient that I'm offering informal admission and if it's declined I'm coming back with pink papers, an AMHP, a GP and an ambulance (with or without police, to convey) since that to my mind could be perceived as somewhat coercive. The argument was that I'd then be admitting people under a section of the MHA 1983 more often than they otherwise needed to be. I typically have just a couple of section 2 admissions a year, I've only made recommendations and managed my patients under section 3 twice in my career to date, so my use of both section 2 and section 3 is lower than colleagues within my peer group.
Different points of view, with different Consultants giving different answers. Usually you ask half a dozen Consultant Psychiatrists a question and you get half a dozen different answers. Unusually we had agreement with just 2 camps and recognition that the opposing camp had valid views but maintaining strong views that their camp was the best way to practice.
I was surprised by how useful the case based discussion was. I'd expected a tedious hour. The open exploration of implications of different approaches to practice, reflection on how we worked and discussion of alternate view points was stimulating and genuinely useful.
A pleasant surprise.
Saturday, 26 February 2011
Friday, 25 February 2011
Advice
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!
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.
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
Transition
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?
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?
Thursday, 27 January 2011
Anxiety
We've had this and this paper look at antidepressant medication use in mild depression.
Yesterday we had updated guidance on the use of medication in the management of anxiety. NICE guidance now is that, "GPs should not offer benzodiazepines or antipsychotics to patients presenting with generalised anxiety disorder (GAD)," the one page summary is here.
Will that mean their drugs budget comes over to me, so I can treat them then? :P
Yesterday we had updated guidance on the use of medication in the management of anxiety. NICE guidance now is that, "GPs should not offer benzodiazepines or antipsychotics to patients presenting with generalised anxiety disorder (GAD)," the one page summary is here.
Will that mean their drugs budget comes over to me, so I can treat them then? :P
Tuesday, 25 January 2011
Overheard
A patient has great understanding of other people. She's worked in the hospitality industry so has worked with large numbers of people all her life. She's often been a kindly ear to those with troubled needs.
Recently she's needed a bit of help.
On discussing how she's an incredibly resourceful soul with plenty of ideas for others' problems, so has the tools in her toolbox to manage with a helpful steer, she smirked at me and told me, "It's easier to look into a goldfish bowl than to be in one."
Insight and genius, all in one.
Recently she's needed a bit of help.
On discussing how she's an incredibly resourceful soul with plenty of ideas for others' problems, so has the tools in her toolbox to manage with a helpful steer, she smirked at me and told me, "It's easier to look into a goldfish bowl than to be in one."
Insight and genius, all in one.
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