capacity, risk & making difficult decisions
TRANSCRIPT
CAPACITY, RISK & MAKING DIFFICULT
DECISIONS
R Zacharias MD
The Planning Committee for this event has
done the following in the interest of Mitigating
Potential Bias:
• All PPC members and speakers have signed a COI form.
• All speakers have been emailed the certification/accreditation requirements for their presentation.
• Each presentation will be reviewed by the Academic Coordinator prior to its delivery. The coordinator will be looking for any signs of bias including use of brand names and logos of pharmaceutical companies.
• If bias is detected the PPC would review it and the speaker would be notified so that the bias can be corrected before the presentation is given. If the bias cannot be corrected or removed the session would be cancelled.
• If a bias is detected by a planning committee member during the presentation they would question the speaker about it.
• All biases would be reviewed at the next PPC meeting.
GOALS & OBJECTIVES
➤ build collegiality - meet and greet
After attending this session participants will be able to:
➤ define both the Health Care Consent Act (HCCA) & the
Mental Health Act (MHA)
➤ define when it is appropriate to treat without consent
➤ manage intoxicated patients in the ER
➤ discuss chemical restraint options
Conflict of Interest Declaration:
Presenter:
Rose Zacharias MD
Title of Presentation:
Capacity, Risk & Making Difficult Decisions
I have no financial or personal relationships to disclose
REFERENCES
Health Care Consent Act
https://www.ontario.ca/laws/statute/96h02
Mental Health Act
https://www.ontario.ca/laws/statute/90m07
CASE 1
➤ 45y/o male
➤ obviously intoxicated
➤ picked up by OPP for “behavioural disturbance” & brought to ER
➤ heading to the cells but pt states “You can’t keep me here, you’re
all a bunch of quacks, let me go!”
➤ AVSS & screening labs ok except Etoh=45
➤ after 1 hour in A12 asks to pee, security accompanies pt to
bathroom but upon exiting A12 bolts for the door
➤ nurse asks what you want to do with this guy and says “if we are
going to keep him you need to Form him”
CASE 2
➤ 36y/o female brought in by OPP with her 2 young kids from the
scene of a domestic dispute
➤ c/o shoulder pain form being restrained by her partner
➤ hx of depression & anxiety
➤ no beds available at the shelter
➤ tox screen +ve for benzodiazapenes and THC
➤ medically cleared w dx = shoulder sprain, awaiting crisis but
getting impatient, wants to leave
CASE 3
➤ 23y/o male apprehended from scene of MVC, non-belted driver
struck a tree at ~50km/hour on city street
➤ slurring and c/o headache
➤ OPP intend to press charges but brought to ER for medical
assessment
➤ after 30 minutes in A12 becomes belligerent and wants to leave,
states his headache is gone, refusing blood work, shouts “I’m
not going to hurt anybody, just let me go!”
HEALTH CARE CONSENT ACT
➤ an Ontario law that has to do with consent and capacity to
treatment
➤ HCCA states that a person has the right to consent to or refuse
treatment IF they have mental capacity
➤ CAPACITY = the ability to understand and appreciate the
consequences of the treatment decision
CAPACITY
➤ the ability to both UNDERSTAND information relevant
to the decision
➤ & to APPRECIATE the consequences of that decision
CAPACITY
➤ …deals with the process of decision-making and does not
depend on the actual choice made
➤ …is not a single ability that people have or don’t have - we use
different abilities to make different kinds of choices - capacity is
task-specific
MENTAL HEALTH ACT
➤ an Ontario law that governs detention in a psychiatric facility
➤ MHA is applied when a physician believes that a person is:
➤ a harm to self
➤ a harm to others
➤ unable to care for self
➤ AND if the physician believes that the person is suffering from
a mental disorder that will result in any of the above
then that physician may apprehend that person for psychiatric
assessment
EMERGENCY TREATMENT WITHOUT
CONSENT
➤ A treatment may be given without consent to an apparently capable
person IF:
➤ communication isn’t possible (language barrier, disability)
➤ steps have been taken to find means to communicate but still
unsuccessful
➤ the delay required to find means to communicate will prolong the
patient’s suffering or put the patient at risk of sustaining serious
bodily harm
➤ there is no reason to believe that the person does not want
treatment
ALL THIS MUST BE DOCUMENTED BY THE PHYSICIAN
MANAGING INTOXICATED PTS IN ER
➤ what are our legal obligations?
➤ informed consent ever be obtained from an intoxicated pt?
➤ what to do when an intoxicated pt refuses PE or tx?
➤ can an aggressive pt be physically or chemically restrained?
➤ legal responsibilities when an intoxicated pt is discharged from
ER
IT’S A CHALLENGE!
➤ disruptive
➤ beligerant
➤ noisy
➤ difficult to assess
➤ threat to safety
➤ raises stress level of staff and
other pts in ER
*risky b/c urgency can lead to
errors & harm
DUTY TO CARE
➤ by law, ER staff @ any 24/7
public hospital has a duty of
care to all who present for
medical services, including
those who are intoxicated
➤ includes duty to attend, dx,
treat and provide d/c
instructions
*can charge nurse advise pt to
leave?
MANAGING INTOXICATED PTS IN THE ER
➤ appropriate physical restraint may be necessary to complete the
assessment to determine if a medical emergency exists (via
security/OPP)
➤ this must be weighed vs. the pt’s capacity/competence
➤ if a pt can understand the information relevant to the decision
and appreciate the consequences of accepting or refusing,
then they are competent, EVEN IF THEY ARE UNDER THE
INFLUENCE OF ETOH/DRUGS
➤ if pt is not competent, and there is imminent threat to health,
MD has duty to do what is immediately necessary EVEN
WITHOUT CONSENT (consent should be obtained from SDM
ASAP and DOCUMENT!)
QUESTION
➤ If a patient is intoxicated, should they be considered incapable of
giving consent?
“ NO.
Assessment of capacity is a clinical one.
It is not based on a lab value such as
blood alcohol level.
-CMPA
QUESTION
➤ Is it appropriate to fill out a Form 1 when an intoxicated pt
refuses treatment?
“ UNLIKELY. Only where a clear mental
illness coexists with intoxication, and
all the criteria are met, would
involuntary admission be appropriate.
-CMPA
QUESTION
➤ When a pt has been restrained, is the attending MD required to
complete a Form 1?
“ Only if the pt meets the criteria of the
MHA, should a Form 1 be completed (ie:
risk & mental disorder) -CMPA
*prudent to clearly document how the MD
determined incapacity & why restraint was necessary
CASE 1
➤ despite intoxication, determine competency
➤ determine if the process of his decision making is sound
➤ if able to understand the decision & appreciate the
consequences and he still wants to go?
…let him go
CASE 2
➤ screen for risk to self, risk to others, inability to care for self
➤ does her “mental illness” result in risk @ this moment?
➤ if YES - Form 1
➤ if NO - and she is competent (appreciate & understand)
…let her go
notify CAS
CASE 3
➤ concern re:agitation resulting from head injury
➤ determine capacity
➤ chemically restrain for CThead
➤ no need for Form 1
➤ covered by the HCCA
➤ Chemical Restraint Options
➤ Olanzapine
➤ Loxapine
➤ Haldol
➤ Clopixal
➤ Lorazepam
➤ Diazepam
THANKS SO MUCH!
ROSE ZACHARIAS - LEAD PSYCHIATRY HOSPITALIST
MARISSA RODWAY-NORMAN - CHIEF OF PSYCHIATRY
OSMH