Thanks to the authors for a helpful article on a controversial
subject.
Aside from the issue of personality disorder, the issue of how what
they term "serious emotional turmoil" can affect Capacity is one that
arises every night in Emergency Departments. Determining Capacity based on
a distressed individual's ability to weigh information in the balance is a
difficult and subjective one. The authors state that "a Casualty officer
at 3 am is unlikely to have the time (and may lack the training and
experience) to do this - Psychiatric colleagues should accept a key role."
However I suspect that Psychiatric colleagues would find the issues
equally difficult, whatever the hour, and that a range of opinions would
be given.
The authors suggest that the Mental Health Act may be used to
administer life-saving physical treatment in this situation. Again, I
suspect this is an issue many Psychiatrists and Approved Mental Health
Practitioners would struggle with. Suicidal thoughts and actions are part
of the definitions of several mental disorders including depression and
borderline personality disorder. The question is whether treating the
physical consequences of these symptoms constitutes a treatment for the
mental disorder itself. The authors argue that it might, but acknowledge
this has not been tested in case law and is not explicit in the statute
law. Also, a substantial proportion of people who present with attempted
suicide are found (on later assessment) not to have a mental disorder
atall. This may be difficult to determine at the time of presentation.
A single statute governing involuntary treatment would as the authors
suggest clarify these issues, but seems a distant prospect. A judicial
review of a Coroner's decission on grounds of Public Law Principles might
have brought a quicker result, but is required within 3 months of a
verdict. Simillarly, an appeal under Human Rights legislation must be made
by the person(s) affected by the decission.
For now, the implications seem to be that at 3 am, Casualty Officers
should get a senior opinion, and in cases of doubt, should err on the side
of intervening to preserve life, rather than respecting autonomy which may
turn out to be absent.
Rapid Response:
What to do about treatment refusal at 3 am?
Thanks to the authors for a helpful article on a controversial
subject.
Aside from the issue of personality disorder, the issue of how what
they term "serious emotional turmoil" can affect Capacity is one that
arises every night in Emergency Departments. Determining Capacity based on
a distressed individual's ability to weigh information in the balance is a
difficult and subjective one. The authors state that "a Casualty officer
at 3 am is unlikely to have the time (and may lack the training and
experience) to do this - Psychiatric colleagues should accept a key role."
However I suspect that Psychiatric colleagues would find the issues
equally difficult, whatever the hour, and that a range of opinions would
be given.
The authors suggest that the Mental Health Act may be used to
administer life-saving physical treatment in this situation. Again, I
suspect this is an issue many Psychiatrists and Approved Mental Health
Practitioners would struggle with. Suicidal thoughts and actions are part
of the definitions of several mental disorders including depression and
borderline personality disorder. The question is whether treating the
physical consequences of these symptoms constitutes a treatment for the
mental disorder itself. The authors argue that it might, but acknowledge
this has not been tested in case law and is not explicit in the statute
law. Also, a substantial proportion of people who present with attempted
suicide are found (on later assessment) not to have a mental disorder
atall. This may be difficult to determine at the time of presentation.
A single statute governing involuntary treatment would as the authors
suggest clarify these issues, but seems a distant prospect. A judicial
review of a Coroner's decission on grounds of Public Law Principles might
have brought a quicker result, but is required within 3 months of a
verdict. Simillarly, an appeal under Human Rights legislation must be made
by the person(s) affected by the decission.
For now, the implications seem to be that at 3 am, Casualty Officers
should get a senior opinion, and in cases of doubt, should err on the side
of intervening to preserve life, rather than respecting autonomy which may
turn out to be absent.
Competing interests: No competing interests