The following document was written by Dr Satvir Singh FRANZCP (Aust), FRCPsych (UK), MSc (Lon), MRCPsych (UK), DPM, MBBS Consultant Psychiatrist & Lead Consultant for Undergraduate Medical Education (Psychiatry) Kent & Medway NHS and Social Care Partnership Trust Canterbury, Kent in Dec 2007.
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CLINICAL RISK ASSESSMENT IN PSYCHIATRY - 2
The Management of Suicidal patient and Deliberate Self-Harm in Accident & Emergency
This section should be read in conjunction with the article on Clinical Risk Assessment in Psychiatry – 1. It is relevant to all medical staff working in Accident and Emergency (A/E).
There are some basic principles that one should follow in all cases, whether the patient is presenting with superficial laceration of arm or a middle aged man has been brought in following a serious suicidal attempt.
Step 1 – Make sure that the patient is medically safe and all vitals signs are stable. If not, then treat accordingly.
Step 2 – In case of overdose, where possible, find out what the patient has taken and if necessary, contact the National Poison Centre for advice regarding immediate management.
Step 3 – Ask a colleague or nursing staff who is assisting you in the patient’s assessment and management to contact the patient’s family, as they will not only give you an objective account of the patient’s recent physical and mental health history, social circumstances and other relevant life events, but would also help you in the management of the patient, especially if you do decide to discharge the patient. Also, arrange the medical notes, psychiatric notes, if any, and GPs medical history/notes print out to be available to you. These days most A & E departments would have access to the patient’s notes on the computer.
Step 4 – Arrange to speak to Community Psychiatric Nursing Staff and other medical staff in psychiatry, if they have been involved with the patient in the past or indeed he/she is under their care currently. They would be able to provide you with useful information about the patient’s past/current mental health issues, social circumstances, current stressors and the past/current prescribed psychiatric treatment, and their opinion about the patient’s further psychiatric management.
Step 5 – Make sure that you have arranged the essential investigations, i.e., routine bloods, illicit drug screening, alcohol levels and glucose levels. If relevant, arrange for ECG and X-Ray chest and CT Brain Scan. For anyone who is intoxicated (alcohol/drugs), it is essential to arrange a CT Brain Scan to exclude the possibility of a subdural haematoma. Such patients have a tendency to bang their heads prior to their arrival to A/E, and they may not be able to give you the relevant history.
Step 6 – Take a brief history and carry out a detailed Mental State Examination and thereafter make a decision about the patient’s further management as follows:
- If the patient is at Minimum Risk for any future adverse event and is medically fit, then she/she can be discharged from the A/E.
- Make sure that the patient is discharged in the care of a responsible adult member of family or friend.
- Arrange for a Mental Health Crisis Assessment Team staff to see the patient in the next 48 hours, or earlier if necessary.
- Notify the GP about the patient.
- Give contact details of Mental Health Crisis Assessment Team for any emergency.
- If for any reason, you cannot get hold of a responsible family member/friend, (sometimes the patient will not give you the consent to contact anyone), then you may consider involving the Crisis Assessment duty staff or Psychiatric Liaison Service, whichever is appropriate in your area, to assess the patient before you let them go.
- If the patient is at Moderate Risk, then he/she should not be discharged in the community. These patients will require to be assessed by the Crisis Assessment Team and/or Psychiatric Liaison Service, whichever appropriate, who will decide about the patient’s further management.
- If the patient is at Severe Risk, then they need to be transferred to the psychiatric in-patient unit for a period of further observation and treatment.
Consent to Treatment and Mental Capacity
It is essential that you understand fully the principles of valid informed consent and follow it at all times in clinical practice. These principles are as follows:
- Consent from a patient is required prior to any examination, treatment of any adult.
- The consent has to be voluntary, free from any pressure or undue influence from the medical profession, family or others
- The consent can be oral, written or even non-verbal. A signature on a form does not necessarily mean that the consent is well informed and valid.
- The patient needs to have sufficient information about the prescribed treatment/procedure, its benefits and risks and what alternative treatments are available, before he/she is able to give the consent for it. Any information given to the patient should be in plain understandable English and if the treatment/procedure is of a complex nature, the relevant information should also be given in writing.
- Ideally, the treating doctor should take the consent for the treatment. However, in practice, it is in order if the junior member of the medical team seeks the consent, as long as he/she feels competent and confident about it and has observed more experienced doctors seeking consents earlier. More significantly, he/she is confident in giving all the relevant information to the patient.
- It is always advisable and good practice, both medically and legally, to record the patient’s decision about the prescribed treatment/procedure.
Refusal to Treatment
- A competent adult can refuse the treatment, even when it would be seriously detrimental to his/her health.
- Similarly, a competent pregnant woman can refuse the treatment even if her decision would be detrimental to the foetus.
- No other person can give consent on behalf of a competent adult.
Children and the Consent to Treatment
- Under English Law, an adult age 18 years and over is considered to be capable giving or refusing consent to treatment.
- However, in practice, a person between the ages of 16-18 is considered to be capable of giving consent without the involvement of parents.
- A competent child under the age of 16 years can give consent for his/her certain treatments without the involvement of parents.
- However, in complex medical/surgical treatments, parents’ consent is essential.
- If the child is unable to understand the details of the prescribed procedure/treatment, then someone with parental responsibility can give the consent on his/her behalf.
Adults who are not Competent to Give Consent to Treatment
- No other person can give consent on behalf of an incompetent adult.
- However, you may still treat them if it would be in their best interest and without the treatment, the outcome is likely to be of grave harm or death of the patient in the immediate future.
- You may treat an incompetent patient in an emergency that poses serious harm/danger to others.
- When you decide to treat a patient who is incompetent (lacks capacity), it is wise to consult other colleagues/health professionals who may or may not be involved with the patient’s management and a record should be kept of the reasons for the treatment.
- A note should also be made that the prescribed treatment, as far as you know, is not in any way against the patient’s religious or spiritual beliefs.
Assessment of Competence (Mental Capacity)
A patient may lack the capacity by reasons of:
- Young age
- Learning disability
- Mental disorders
The Process to Assess the Mental Capacity
Step 1 – Provide the relevant information in plain English with regard to the specific decision that the patient is expected to make. Also, advise the patient about the pros and cons of the other alternatives, options and decisions.
Step 2 – Assess the patient’s cognitive ability whether he/she:
- Understands the given information and the decision that he/she has to make
- Is able to retain the given information
- Is able to consider the pros and cons of his/her decision and its implications.
Step 3 – Assess as to why the patient is unable to reach a decision. This could be due to various mental disorders or other reasons. However, presence of a mental disorder does not necessarily mean that the patient does not have mental capacity. Also, a patient may have capacity in one area but not in other.
Summary
- A competent adult has the civil right to self-determination and cannot be forced to receive medical treatment just because it is in his/her best interest, in your carefully considered opinion.
- However, you have the right to treat and adult in case of emergency where without the immediate medical intervention, the outcome may lead to serious harm or death of the patient.
- Under the Mental Health Act 1983, you have the right to treat an adult against his valid informed consent if he/she is thought to be suffering from a mental disorder.
- A competent adult has the autonomy to withdraw his/her consent at any time.
The next section deals with The Management of Suicidal and Deliberate Self-Harm Patients in Community
Author:
Dr Satvir Singh
FRANZCP (Aust), FRCPsych (UK), MSc (Lon), MRCPsych (UK), DPM, MBBS
Consultant Psychiatrist & Lead Consultant for Undergraduate Medical Education (Psychiatry)
Kent & Medway NHS and Social Care Partnership Trust
Canterbury, Kent
References:
- Shorter Oxford Textbook of Psychiatry, Fifth Edition, M Gelder et al, 2006
- Department of Health - Consent
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