clinician training advance health directive for mental ... · section 8: signature and witnessing...

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Training presented by:

Funded by:

Mental Health Act 2016

Clinician TrainingAdvance Health Directive

for Mental Health (AHD-MH)

AHD-MH training for Queensland Health

- health professionals & mental health services

NB: State-wide

version 31 May 2018

Welcome & Introductions

Welcome

Acknowledgement of Country

About “Advance Health Directives for

Mental Health (QLD, Australia)”

YouTube Video Resource [DURATION: 6min 41sec]

� Access via ADA Website:

https://adaaustralia.com.au/clinicians/

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Focus

� What is an Advance Health Directive for Mental Health (AHD-MH)

� Why complete

� Who can complete

� When it starts

� How to complete

MHA2016: Strengthening rights using least restrictive options

� Engage, equip and empower clinicians

� Identify if a person has an AHD-MH

� Assist a person to make or update an AHD-MH

� Storing, Review, Updating & Revoking

Clinician’s role

� Depending on your role, you may be responsible for:

� Checking the state-wide system (CIMHA/The Viewer)

� Following an AHD-MH to ensure less restrictive way

� Assisting a person to make an AHD-MH

� Liaising with a person’s GP, Allied Health Professionals, Attorney/s etc.

� Encouraging a person to make, review and/or update AHD-MH

� Maximising patient autonomy is everyone’s responsibility!

� Achieve the principles & objects of MHA2016

� Read & adhere to

� Chief Psychiatrist’s policy

� Guide to Advance Health Directives, Enduring Powers of Attorney, Guardians and Administrators (attachment to QH CPP Policy for AHD & Less Restrictive Way)

Patient autonomy is the ideal

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Chief Psychiatrist Policy: Advance Health Directives and ‘Less Restrictive Way’ of Treatment (March 2017)

https://www.health.qld.gov.au/__data/assets/pdf_file/0029/465176/cpp-advance-directives.pdf

� Policy – Section 5

� 5.1: Obligations of health practitioners

� 5.2: Requirement to consider less restrictive way of treatment

� 5.2.1: Presumption of Capacity; Principles of supported decision-making; rights to consent

� 5.2.2: Minors

� 5.2.3: Must take steps to identify if AHD exists; and/or appointed an attorney, or has guardian

� 5.2.4: Statutory Health Attorney (SHA)

� 5.2.5: Must document in record if being treated by AHD; or under consent of attorney / guardian

� 5.2.6: If less restrictive way becomes available at a future time

� 5.3: Use of physical restraint in providing treatment and care

� 5.4: Treatment as an inpatient

� 5.5: When requirement to treat in a less restrictive way does not apply

� 5.6: Ongoing lack of capacity

� 5.7: Making an AHD for future health care

� 5.8: Urgent health care

MHA2016 commenced 5 March 2017

� Objectives to be achieved in a way that:

� Safeguards the rights of persons

� Is the least restrictive of the rights and liberties of

a person who has a MI, and

� Promotes the recovery of a person who has a MI,

and the person’s ability to live in the community,

without the need for involuntary treatment and care

Mental Health Act 2016 (Qld)

MHA2016 Part 2 Principles for administration of Act https://www.legislation.qld.gov.au/browse/inforce

Principle of ‘less

restrictive way’

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MHA2016: Principles for persons with MISection 5

� Same human rights

� Matters to be considered in making decisions

� Support persons

� Provision of support and information

� Achievement of maximum potential and self-reliance

� Acknowledgement of needs

� Aboriginal and Torres Strait Islanders

� Persons from culturally and linguistically diverse backgrounds

� Minors

� Maintenance of supportive relationships and community participation

� Importance of recovery-oriented services and reduction of stigma

� Provision of treatment and care

� Privacy and confidentiality

Principles that apply to

administration of MHA2016

Future choices & consent for when unwell

� Treatment and care

� Attorney/s

� Inpatient stay? Physical restraint?

� Eligible Doctor certification required

Access the form (print version or online version)

health.qld.gov.au/mental-health-act

Optional

in QLD

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Who can make an AHD-MH?

� Adults 18 years and over who have capacity

Considerations:

�Presumption / Fluctuating / Maximise

�Capacity to make an AHD-MH (POA criteria)

�Capacity to consent to treatment (s14 MHA2016)

Queensland Centre for Mental Health Learning (Learning Centre)

Capacity Resources: eLearning & Face-to-Face

www.qcmhl.qld.edu.au

• QC 13 Capacity Assessment [Face-to-face workshop]

• QC40 Capacity Assessment Training and Advance Health Directives

[online / eLearning course]

Optional form

MHA2016s 12

Capacity to consent to be treated - Defined in s 14 MHA2016

Please refer ‘Queensland Legislation’ Qld Govt. site online

for the most recent

version of MHA2016

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MHA2016 A key

objective of

the MHA2016

Definition:

Capacity to consent to treatment

s 14 MHA2016� Refer s12(1)(b) MHA2016

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Capacity to make

an AHD-MH

� Adults (18 years +) with capacity

� Criteria to make an AHD as per:

Powers of Attorney Act 1998 (Qld) Section 42

[Chapter 3 Enduring documents]

Who can assist a person with an AHD?

� Clinicians / health professionals / case workers / health workers

� Any identified supporter or advocate

� Independent Patient Rights Advisers (IPRAs)

� Located in Hospital and Health Services (HHS)

� Advise patients of their rights under MHA2016

https://www.legislation.qld.gov.au/view/html/inforce/current/act-2016-005#sec.293

� A person can request the support of an IPRA

� treating team to action if request made

Please contact

your local IPRA

service

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MHA2016 Requirements: Role and Function of the IPRAs

IPRAs are required to work with the patient, and their nominated support persons, family, carers and

other support persons to:

Ensure that they are advised of their rights and responsibilities under the Act.

Help communicate the patient’s views, wishes and preferences about their treatment and care to

health practitioners.

Develop their understanding of the Mental Health Review Tribunal (MHRT) processes and their

rights at the hearing and organise a representative for the MHRT, including legal support or

advocacy, if requested.

Develop their understanding of the benefits of an AHD for mental health and the EPOA role for a

personal matter, if appropriate.

Additionally, IPRAs are required to:

Consult with authorised mental health practitioners, authorised doctors, administrators, and the

Chief Psychiatrist on the rights of patients under the Act, the Guardianship and Administration Act

2000 and the Powers of Attorney Act 1998.

Work cooperatively with any personal guardian or attorney to further the patient’s interests.

Work cooperatively with Community Visitors under the Public Guardian Act 2014.

Person to access /

download a copy of the

AHD-MH guide/form;

and read carefully

Person to think about

views, wishes, preferences for future

mental health care

Person to discuss with

family, carers, GP/Doctor,

psychiatrist / treating team and/or others as the person

wishes

Person to consider

attorney/s and specify any

limitations or conditions on decisions that attorney/s can

make

Person to meet with Doctor to

discuss treatment

preferences

Eligible Dr signs Section 7 –AHD-MH

Dr certification - Capacity

Person to meet with an

eligible witness

(JP or lawyer)

Person to sign AHD-MH

presence of witness

Person to keep original, get certified copies for

public mental health service

+ GP+ attorney/s & any others

Person to review and

update regularly –

at least every 1-2 yrs

Dr to sign updated AHD-MH

Quick steps to completing an Advance Health Directive for Mental Health

Doctor Certification (Section 7 of AHD-MH) – Step 5*

Read and understood ‘Involvement of a doctor’ (page 3 of the Guide/form)

The person making the AHD-MH appears to have capacity to make the directive

I am eligible to make this certification

1 2 3 4 6 7 85*

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Best Practice TipsAdvance Health Directives for Mental Health

Conversation starters

� ENQUIRE

� Existing? Aware of?

� ENCOURAGE

[1] What treatment would you prefer if you were unwell and could not make decisions?

[2] Who would you like helping you with personal decisions such as mail, paying bills?

[3] Who would you like to make decisions for you if you can’t make them for yourself?

� Right person? Had discussion? Trusted to make and follow wishes?

� EXPLAIN

� Choice of language + detail based on mental health history

*Reference: Questions modified from Decision Assist (VIC) – Webinar (Jan 2017)

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Conversation tips

� Have you done an AHD before?

� Do you know an AHD can help you have your say in future care if you were unwell?

� What has worked well in the past?

� What treatments/medications did or did not work?

� What do you want treatment and care to look like?

� What past experiences do you want to avoid in the future?

� If you were unwell, would you agree to a hospital stay for you own safety?

� Who would you like supporting you in a crisis? Anyone you do not want to help?

� What arrangements would you need to make to keep everything going at home?

(e.g. mail, bills, pets, kids, plants, work, emails)

� What other health professionals need to know you are unwell?

� Do you want to make changes to your AHD?

Key considerations …

� Episodic nature of MI / fluctuating capacity

� Impact of general medical health issues

� MI history

� Risks & patterns of behaviour

� Past presentations good indicator for future presentations

� Respecting choices & treating in the less restrictive way (when possible)

� Involving support person/s

� Transcultural mental health

� RANZCP Guidelines – Indigenous Mental Health

www.ranzcp.org/Publications/Indigenous-mental-health.aspx

AHDs are not a

demand for treatment –consider, respect, uphold where

possible

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[Overview AHD-MH]

� Section 1 – Personal Details

� Section 2 – Consent to healthcare and my views, wishes and

preferences � Consent to healthcare [Page 1 of 5]

� Views, wishes and preferences [Page 2 of 5]

� Section 3 – Appointing an attorney [Page 2 of 5]

� Section 4 – Conditions of attorney appointment [Page 3 of 5]

� Section 5 – Use of physical restraint [Page 4 of 5]

� Section 6 – Authority to remain in an inpatient unit [Page 4 of 5]

� Section 7 – Doctor certification [Page 4 of 5]

� Section 8 – Signature and witness [Page 5 of 5]

[Form] Advance Health Directive for Mental Health

consents to or does not consent to

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� Optional to appoint 1 or more attorneys

� Attorney acceptance required

� Appointment only effective when person lacks capacity to consent to treatment

� Attorney/s must follow directions stated

� Conditions and Limitations


� Must only be the minimum necessary and only for as long as is necessary

� Consents or does not consent (Self + Attorney/s)

� Only if necessary for treatment and care, and only for as long as is necessary

� Review undertaken after 14 days by a Clinical Director

� TA & MHRT review

� Read page 3 of ‘Guide and Form’ https://www.health.qld.gov.au/__data/assets/pdf_file/0036/639864/Advance-Health-Directive-Guide-and-Form.pdf

� Must sign to certify the person appeared to have capacity

Person to discuss AHD-MH

with Doctor

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[Form] Making Valid + Review

Section 8: Signature and Witnessing of the form

� Sign with eligible witness, i.e. a JP, lawyer, or Commissioner of Declarations who:

� Is at least 21 years of age

� Is not a paid carer or health provider for the person making AHD

� Is not a beneficiary under the person’s will

� Is not the person signing for the person if they are unable to sign

� Is not one of the appointed attorneys, or a relation of nominated attorney/s

Recommendation: Prepare certified copies

Review of the form

� Any time the person has capacity

Recommendation: Review every 1 – 2 years, or as preferences change

Guide person to local JP

signing areas NB: IPRA

service may also be able to

guide

Treatment Authorities (TA)

Is AHD-MH enough to keep the person and/or others safe?

When to use a TA if an AHD-MH exists?

�Use when treatment/care needs are greater than

treatment preferences

� Discuss and document reasons as per MHA2016 s 54

� Respect residual capacity

� If TA, non-treatment aspects of AHD-MH may still be followed

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When requirement to treat in a less restrictive

way does not apply

� Refer to QH Chief Psychiatrist Policy “Advance Health Directives and ‘Less Restrictive Way’ of

Treatment”

� Section 5.5

� See also legislation: MHA2016 – Section 13 (extract below or refer to current version of MHA2016 online Qld Govt. Queensland Legislation site)

Queensland Consumer Resources & Videos:

Video: About the Advance Health Directive for Mental Health

Video: Completing the AHD-MH form

https://youtu.be/TSkP1xtlWBc

https://www.youtube.com/watch?v=U2MwR2h_F4Y

https://adaaustralia.com.au/clinicians/


Guide people to watch videos

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GuidelinesThe RANZCP produces guidance to help psychiatrists and other mental health professionals in their work.

� Best Practice:

� The Royal Australian and New

Zealand College of Psychiatrists

(RANZCP)www.ranzcp.org/Publications/Guidelines-and-resources-for-practice.aspx

Discussion / ActivityEngage, Equip & Empower clinicians

Consider

� Would you feel confident assisting a person to complete their

AHD-MH if they approached you?

� Do you know where to locate the document?

� Have you engaged with IPRA roles?

� Have you encouraged the involvement of support person/s?

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Evidence suggests …

� Loss of capacity is likely to be episodic (3)

� Individual variation with decision-making (3)

� Directives allow a more informed and open dialogue

� Collaborative approach when drafting (4)

� Written directives usually indicates more stable preferences (1)

� Compliance improved with specific detail and attorney/s

� Review patient wishes over time (1)

E.g. UK Case [refer to Factsheet 7 https://adaaustralia.com.au/clinicians/]

Re E (Medical treatment: Anorexia) [2012] EWHC 1639 (COP)

Formal & detailed capacity assessment to be undertaken and documented

Evidence - References [1] Danis M et al., ‘Stability of Choices about Life-sustaining Treatments’ (1994) 120(7) American College of Physicians 567

[2] Loewy E, ‘Changing One’s Mind: When is Odysseus to Be Believed?’ (1988) 3 Journal of General Internal Medicine 54

[3] Ritchie J et al., ‘Advance Directives in Psychiatry – Resolving Issues of Autonomy and Competence’ (1998) 21(3) International Journal of Law and

Psychiatry 245

[4] Ryan C, ‘Betting your life: an argument against certain advance directives’ (1996) 22 Journal of Medical Ethics 95

[5] Winston M et al., ‘Can a Subject Consent to a ‘Ulysses Contract’?’ (1982) August The Hastings Center Report 26

[6] Loewy E, ‘Ethical Considerations in Executing and Implementing Advance Directives’ (1998) 158 (Feb 23) Archives of Internal Medicine 321

[7] Gross M, ‘What Do Patients Express as Their Preferences in Advance Directives?’ (1998) 158 (Feb 23) Archives of Internal Medicine 363

[8] Re E (Medical treatment: Anorexia) [2012] EWHC 1639 (COP)

[9] Del Villar, ‘The Enforceability of Mental Health Advance Directives: The Legal Limits of Personal Autonomy’ (PhD Thesis, Faculty of Law, QUT, in

progress) [2018/2019]

[10] Ganzini MD et al., ‘Pitfalls in Assessment of Decision-Making Capacity’ (2003) 44:3 Psychosomatics 237

[11] Williams K, ‘Advance care directives in Queensland: Two sides of the coin’ (2017) July Proctor 22

[12] Simpson et al., ‘Recovery-focused care planning and coordination in England and Wales: a cross-national mixed methods comparative case study’

(2016) 16 BMC Psychiatry 147

[13] Kisely et al., ‘Motivational aftercare planning to better care: Applying the principles of advance directives and motivational interviewing to

discharge planning for people with mental illness’ (2016) 26(1) International Journal of Mental Health Nursing 41

[14] Sellars et al., ‘Australian Psychiatrists’ Support for Psychiatric Advance Directives: Responses to a Hypothetical Vignette’ (2017) 24(1) Psychiatry,

Psychology and Law 61

[15] Davidson et al., ‘Supported decision making: A review of the international literature’ (2015) 38 International Journal of Law and Psychiatry 61

[16] Davidson et al., ‘An international comparison of legal frameworks for supported and substitute decision-making in mental health services’ (2016)

44 International Journal of Law and Psychiatry 30

[17] Bellesheim K, ‘Ethical Challenges and Legal Issues for Mental Health Professionals Working with Family Caregivers of Individuals with Serious

Mental Illness’ (2016) 26(7) Ethics and Behavior 607

[18] Devi et al., ‘Moving towards substituted or supported decision-making? Article 12 of the Convention on the Rights of Persons with Disabilities’

(2011) 5 ALTER, European Journal of Disability Research 249

[19] State Government of Victoria, ‘Advance care planning: have the conversation – A strategy for Victorian health services 2014-2018’ (2014) Access

online https://www2.health.vic.gov.au/hospitals-and-health-services/patient-care/end-of-life-care/advance-care-planning

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Capacity Assessment

CapableIncapable

Capacity to consent to be treated?

Simple Complex

� Consider and assess other matters separately

� General health decisions

� Completing AHD or EPOA

� Remember capacity often fluctuates

Does the person have the capacity &

understanding to make an AHD-MH?

Capacity is a sliding scale – focus needs to be on the

question being asked

Decision-making alternatives if persons lack capacity*for mental health treatment and care decisions

Guardian:Application to Queensland Civil and Administrative Tribunal (QCAT) can be made for:

[1] a Guardian for personal / healthcare decisions.

Appointments can be reviewed at QCAT with correct QCAT forms.

Enduring Power of Attorney (EPOA): When persons have capacity they can also make an EPOA and appoint personal attorney/s.

Statutory Health Attorney (SHA): Spouse, carer, family or friend.

Option of last resort: The Public Guardian of Queensland.

Advance Health Directive for Mental Health (AHD-MH): Provides future consent for mental health treatment and care + other health matters for

when persons lack capacity to make decisions due to mental illness.

Advance Health Directive (AHD): Provides a future healthcare agreement for general healthcare, and end of life matters.

AHDAHD -MH

Guardian

EPOA

SHA

Less restrictive

way

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Chief Psychiatrist Policy: Advance Health Directives and ‘Less Restrictive Way’ of Treatment (March 2017)


QH Chief Psychiatrist Policy

Advance Health Directives and ‘Less Restrictive Way’ of Treatment


(March 2017)

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Chief Psychiatrist Policy: Advance Health Directives and ‘Less Restrictive Way’ of Treatmenthttps://www.health.qld.gov.au/__data/assets/pdf_file/0029/465176/cpp-advance-directives.pdf

Building on existing plans

Recovery-oriented practice

Partnership to complete realistic future care plans

AHD-MH

Care Plan

Discharge Plan

My Recovery

Plan

Relapse Prevention

Plan

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AHD-MH Training Resources

https://adaaustralia.com.au/clinicians/� Fact sheets

� Factsheet 1: About Advance Health Directives for Mental Health (AHD-MH)

� Factsheet 2: Decision-making and Capacity

� Factsheet 3: Frequently Asked Questions

� Factsheet 4: Glossary

� Factsheet 5: Useful Resources and Information

� Factsheet 6: Empowering 8 Steps for consumers to make an AHD-MH

� Factsheet 7: International Case Note

� QLD Health Checklist

https://www.health.qld.gov.au/__data/assets/pdf_file/0027/641169/Checklist_AHD_signing.pdf

MHA2016 Evaluation

Opportunities to provide feedback on the Mental Health Act 2016

https://www.health.qld.gov.au/clinical-practice/guidelines-

procedures/clinical-staff/mental-health/act/evaluation

More information about the Mental Health Act 2016 (Qld)


More information on AHD-MH?

adaaustralia.com.au/clinicians

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Summary for AHD-MH

� Ask about existing

� Assist people with making

� Check state-wide system/s (i.e. CIMHA / The Viewer)

� Read and consider

� Remember section 54 MHA2016 – When an AHD not followed

� Review the AHD-MH regularly with the person

� AHD-MH Resources for Clinicians: https://adaaustralia.com.au/clinicians/

QC40 Capacity Assessment Training and Advance Health Directives – Module 2

Principle of ‘less

restrictive way’

Mental Health Act 2016 resources

Queensland Health resources and information:


• Chief Psychiatrist policies and guidelines

Consumer resources

adaaustralia.com.au/education/advance-health-directives-mh

Online Learning & Face-to-Face courses

Queensland Centre for Mental Health Learning

qcmhl.qld.edu.au

• Online: QC40 Capacity Assessment Training and

Advance Health Directives

• Face-to-face: QC 13 Capacity Assessment

iLearn ilearn.health.qld.gov.au

More information:

• IPRA/s available - Queensland public hospitals

Queensland Health Documents for Consumers*

Guides and Forms

Guide to Patient Rights

Advance health directive for mental health (Guide & Form)

Nominated Support Persons (Guide & Form)

Factsheets

Statement of Rights – Your rights under the Mental Health Act 2016

Patient Rights

Role of Nominated Support Persons

Rights of Family, Carers and Other Support Persons

Advance Health Directives and Less Restrictive Way of Treatment

Brochures

Advance Health Directives

Support Persons

Your Rights

Revocation Forms

Revocation of AHD and Attorney Form

Revocation of Nominated Support Person