1. DETENTION RIGHTS Where do we stand?
Dr. Tristan McGEORGE Registrar
Dr. Andy McCLELLAND Specialist
Department of Emergency Medicine
Peter Le CREN A+ Legal Advisor

2. DETENTION RIGHTS Where do we stand?
INTRODUCTION
CASES x 2
MEDICO-LEGAL FRAMEWORK
THE ROLE OF THE LEGAL ADVISOR
THE ROLE OF LIAISON PSYCHIATRY
DISCUSSION

3. What is important? Patient competence Decision-making capacity
Right to refuse medical treatment
Detention

4. Case 1. Mr. CD 45 year old male arrived by ambulance HISTORY:
‘Assault, thrown through plate glass window’
‘~2000 ml blood loss’
Patient aggressive attitude, would not answer questions

5. Case 1. Mr. CD ASSESSMENT: GCS = 15 A B C = normal
Lacerations anterior NECK x 2
Mental state
‘Appropriate speech’ ‘orientated’ religiose ideation
Refuses surgical treatment

6. Case 1. Mr. CD PAST HISTORY: Paranoid schizophrenia Itinerant
Medication
Respiridone - noncompliant
‘Hepatitis C positive’

7. Case 1. Mr. CD A+ legal advisor consulted
Assessed by psychiatric liaison nurse
Collateral history of recent deterioration in mental state:
Hallucinations, verbal direction from God, inappropriate behaviour
Section 8 mental health act initiated by the Homeless Outreach Treatment Team

8. Case 1. Mr. CD After discussion with patient
Agreed to limited intervention
Collapsed in ED shower / further blood loss - ‘seizure’, rx iv fluids
Transfer to O.T.
Seizure in preop. room; Hb = 53
RBC transfusion total 8 units
Operation: lacerations repaired

9. Case 1. Mr. CD PROGRESS: Admitted post-op to surgical ward
Psychiatry consult:
Detained under section 8 MHA1992
Further detention section10(2)b

10. Case 1. Mr. CD
PROGRESS:
Medical registrar consult re. ‘seizure’ advised CT Scan Head - postponed
Transfer to Connolly Unit
Discharged 2 days later
no acute psychosis
refused voluntary admission

11. Case 2. Mrs. AB 77 year old woman HISTORY:
intentional overdose ~12 hours earlier
Warfarin 5 mg x 10
Digoxin mg x 10
Zopiclone 7.5 mg x 10

12. Case 2. Mrs. AB HISTORY: patient phoned a pharmaceutical company
company phoned ambulance
ambulance phoned GP
and brought patient to ED

13. Case 2. Mrs. AB PAST HISTORY: Vertigo = peripheral and central
Depression and anxiety
Mitral valve replacement
Chronic atrial fibrillation
Poor vision: glaucoma, cataract op

14. Case 2. Mrs. AB ASSESSMENT: GCS = 15 A B C = normal
ECG = 65/minute sinus rhythm, LVH
accepted basic investigations
willing to stay but refusing treatment
life-threatening overdose

15. Case 2. Mrs. AB ‘suicide letter’ ‘Advance Directive’ July 2000
Voluntary Euthanasia Society
member 3 years
Deterioration in ‘quality of life’

16. Case 2. Mrs. AB A+ Legal Advisor consulted assess competency
consider past wishes
inform patient
Liaison Psychiatrist consultation
competent to refuse treatment
Daughter present

17. Case 2. Mrs. AB INVESTIGATIONS INR = 5.8 on arrival
>10 the next morning
DIGOXIN = 2.1

18. Case 2. Mrs. AB PROGRESS Admitted to medical ward No complications
Discharged on day 5 to rest home

19. The meaning of detention
Legal definition
In practice
Deprivation of liberty by physical means
Induce to stay by threats or assertion of authority
Reasonable conclusion that they are not free to go

20. Necessity Requirements for psychiatric detention
Actually mentally disordered
Situation of imminent danger or peril
Necessary in the circumstances
S.62 MHA 1992 –Urgent Treatment

21. A Legal Framework Emergency Situations Crimes Act 1961 Necessity
The Mental Health (CAT) Act 1992
The Bill of Rights Act 1990

22. Context Right to refuse medical treatment (S.11 Bill of Rights Act)
Treatment only with informed consent
(Right 7(1) Code of Patient Rights)
Assault; false imprisonment
Doctrine of urgent necessity

23. Is the patient competent? Partial Is the patient mentally disordered?
Mental Health (Compulsory Assessment
and Treatment) Act 1992
S.8 Application
S.38 Duly Authorized Officer
S.110 Medical Practitioner
S.111 Nurse

24. Patient not competent? I TREAT Right 7(4) Code of Patient Rights
Advance directive?
Legal representative?
Best interests?
Consumer’s view?
Other suitable persons? I
TREAT

25. S.41 Crimes Act 1961
“ Everyone is justified in using such force as may be reasonably necessary in order to prevent the commission of suicide, or the commission of an offence which would be likely to cause immediate and serious injury to the person or property of anyone…”
S.48
Self Defence or Defence of others

26. ADVICE Offer options Fully inform patient Spread risk
Minimum intervention
Documentation – ‘refusal to treat’

27. The role of Liaison Psychiatry
The role of the Legal Advisor
What if they don’t phone back?