The idea of an emergency card carried by patients
with certain conditions - for example, diabetes - is not new. A similar
card for mentally ill patients is also not new: a users' group,
Survivors Speak Out, first introduced a crisis card in 1989, and
interest has since grown.1 Known as a mental health
emergency card, its aim is to enable patients to give advance
directives about their management. As such the card poses particular
problems, not least in relation to the legal status of advance
directives.2 At first sight mental health emergency cards
seem to have something for everyone.3 However,
contradictions in the objectives of different groups have delayed their
widespread implementation and led to an atmosphere of distrust.
Survivors Speak Out, the inventor of the card, has recently withdrawn
its version. Its aim was to increase users' self determination in the
event of a loss of mental capacity. But users now complain that mental
health professionals are increasingly helping patients to complete
their cards.4 They fear that patients will be coerced into
including potentially damaging information.
Different objectives led to trusts developing cards at the request of
the public, professional carers, and the police. For these groups one
of the failures of community care is that some of the most vulnerable
patients are lost to follow up,5 sometimes because of lack
of communication between services. The hope was that the card would
alert professionals to previous contacts with other services.
Finally, the recommendation that the Royal College of Psychiatrists
should develop a card was a response to public concern about violent
mentally ill offenders.3 Thus the public may see these
cards as a way of identifying potentially dangerous patients. The
police and other professionals may also see them as a means of helping
determine disposal - for example, through court diversion schemes.
But professionals also face difficulties in helping people with these
cards. It is unclear whether, in the face of a clear advance directive
on a card, their clinical judgment should be overriden. Despite a
discussion document from the Law Society in 19896 and an
enthusiastic endorsement from the Commons health select
committee,7 the legal status of these cards remains
unclear. Currently both voluntary and non-voluntary bodies are awaiting
the conclusions of a commons working group on the Law Commission
report on mental capacity8 before proceeding with
potential card schemes.
There is no evidence from the UK or elsewhere on the success or
otherwise of mental health emergency cards and on what any success may
depend. In the absence of such data, practical aspects of the card are
also a source of disagreement. Who, for example, should fill it out?
That this has become an issue is probably more a symptom of mistrust
than a fundamental problem. An obvious tension exists between privacy
and information, and many fear that the cards may further stigmatise
ill patients - or, worse, that the information may be used aginst the
holder. One compromise might be simply to include only a contact name
and number (accessible 24 hours) that would provide a bona fide caller
with further information and the name of an advocate for the patient.
Such a card might then be offered widely without suggesting a history
of mental illness, while to some extent meeting the objectives of
different groups. Such minimal information would also fit on to a
necklet or bracelet, which might be more practical for some patients.
Finally, which patients should carry the cards? It is hard to imagine
them being anything but voluntary, and they must certainly not be
simply a knee jerk response to public concern. Whether or not a mental
health emergency card can satisfy both users and professionals remains
to be seen. But the cards will be successful only if patients accept
and use them.
L P Weston
Senior registrar
Shrodells Unit,
Watford General Hospital,
Hertfordshire WD1 8HB
L A Lawson
Senior registrar
New Possibilities NHS Trust,
Bridge,
Essex CM8 1EQ
References
1 MIND. Information crisis fact sheet.
London: MIND, 1995.
2 Law Commission. Mental incapacity. Item 9 of the fourth
programme of law reform: mentally incapacitated adults. London:
House of Commons, 1995: 28 Feb.
3 Report of the enquiry into the care and treatment of
Christopher Clunis. London: HMSO, 1994.
4 Brent Mental Health Users Group Newsletter. Crisis
cards. 1993: 28 October: p 17, col 1.
5 House of Commons Health Committee. Better off in the
community? The care of people who are seriously mentally ill. 28
March 1994, vol 1. London: HMSO, 1994:xix.
6 Mental Health Subcommittee. Decision making and mental
incapacity. London: Law Society, 1989.
7 Brindle D. Card gives user say in treatment.
Guardian 1993; 8 July: p 4, col 3.
8 Lord Chancellor's Department. Press notice. London:
Lord Chancellor's Department, 1995:15 March.
