Whose best interest? Advance Decisions and collaboration in coercive environments
By Owen Spalding
Emma is admitted to hospital under Section 2 of the Mental Health Act. It appears that she is currently experiencing an acute psychotic episode. Whilst on the ward, Emma – who has a significant trauma history – does not want to engage in pharmacological treatment. She does not feel that she is unwell and therefore does not see the benefit of medication. Staff discuss whether Emma should be compelled to take her medication; indeed, her legal status allows staff to administer medication with or without her consent. In reality, ‘without her consent’ means through the use of intramuscular injection, which undoubtedly will require the use of restraint for this to happen. This will be an extremely distressing experience for Emma.
Given her trauma history, the decision is made not to enter into a paradigm of restrictive practices, as this will likely retraumatise Emma and cause her mental state to deteriorate further. Significant collaborative work develops a therapeutic and trusting relationship. Emma is provided with information about different types of medication, and the benefits and side effects are discussed. Eventually, Emma agrees to take medication and – along with concurrent psychological work – recovers sufficiently to leave hospital and continue receiving support in the community.
Staff discuss whether Emma should be compelled to take her medication; indeed, her legal status allows staff to administer medication with or without her consent
This shouldn’t be an alien situation. As mental health professionals, we should be thinking deeply about the ethics of our decision making, and whether or not the actions that we take in situations like the above truly reflect the patient’s best interest. Restrictive practices should be used only as a last resort, and any decision to use coercive interventions should be weighed up in a way that reflects its potential to cause harm. Authentic respect should be encouraged and displayed for the opinions of all involved in care – not just staff. We should be showing empathy and understanding for the potential consequences of our actions and discussing ways in which we can do things better. Listening to different perspectives and asking, “is this the ethically just thing to do?” should be fundamental to our day-to-day, always keeping in mind that legal authority does not give us total liberty to engage in restrictive practices.
However, evidence suggests this is not the case. Figures obtained by Agenda show that around 1 in 5 women admitted to mental health facilities were physically restrained, with evidence from one trust of over 50% of women being restrained during admission. Can we really say that in all these cases the use of restraint, rapid tranquilisation, and other coercive interventions had been weighed up by the team and deemed to be the ethically right and least restrictive option, with consideration given to the patient’s personal history, values, and wishes?
Listening to different perspectives and asking, “is this the ethically just thing to do?” should be fundamental to our day-to-day, always keeping in mind that legal authority does not give us total liberty to engage in restrictive practices.
Indeed, the use of restrictive practices on patients detained under the Mental Health Act as a whole remains a grave concern, with poor experiences of care commonplace among the testimony of those who have been in hospital involuntarily. It continues to be a troubling aspect of the legal authority endowed by the Mental Health Act: whilst restrictive practices and treatment without consent are often only used to maintain safety in the context of staff’s perception of risk of harm to self or others, it cannot be disputed that they have enormous implications for a person’s sense of security, self and autonomy. How do we encourage and foster a culture of collaborative work that recognises and acknowledges the wishes of the patient whilst maintaining an understanding that we may have to act without their consent during times of incapacity?
Much discussion around this topic has centred on Advance Decisions. Advance Decisions allow people receiving medical care to explain how they would like to be treated in future if they are too unwell to tell people what they would like to happen. This can also contain explicit information about treatment that the person would refuse to have in times of incapacity. In England and Wales, if an Advance Decision is written, signed and witnessed, the Mental Capacity Act ensures that its contents are legally enforceable. However, in the case of a person detained under the Mental Health Act, anything in their Advance Decision that is related to their mental health difficulty can be overridden (whilst any refusal for treatment that is related to a physical condition is still enforceable). The Independent Mental Health Act review’s interim report found that many people felt that their attempts to set out treatment decisions related to their mental illness did not receive adequate attention. A patient’s dignity and control over treatment decisions should be universal, but at present we are not providing a level playing field by virtue of their mental health condition.
How do we encourage and foster a culture of collaborative work that recognises and acknowledges the wishes of the patient whilst maintaining an understanding that we may have to act without their consent during times of incapacity?
Some argue that making Advance Decisions legally enforceable under the Mental Health Act, there is a risk that patients may not receive appropriate care. There are also concerns about how patients are to be cared for whilst acutely unwell and refusing treatment. It would not be a step towards more collaborative and less coercive care if – as in the case of Sevels v Cameron – an Advance Decision to refuse all antipsychotic medication resulted in 404 days in seclusion. We cannot enter into a situation where we are just switching one restrictive intervention for another.
This does, however, appear to be an exception to the rule, with much of the research showing that very few patients refuse all treatment. Instead, it appears they are much more likely to refuse some, but also indicate what is preferable. It seems that making Advance Decisions legally enforceable under the Mental Health Act could be a step away from the paternalism that has so long blighted our mental health services. We must recognise that in the Mental Health Act’s current iteration, coercion and detention will continue to be used, but there are ways that we can improve the experience of people who need mental health support whilst lacking capacity. It should be our duty to provide patients with the tools to empower themselves when they are at their most powerless.
It should be our duty to provide patients with the tools to empower themselves when they are at their most powerless.
In Scotland, where Advance Decisions are in statute, many patients choose not to put one in place because it can still be overridden by the team in charge of their treatment. With the Critical Mental Health Nurses Network calling for a national discussion on whether mental health nurses should be able to conscientiously object from the enforcement of treatment on patients, the scope of the debate continues to grow. If we truly want mental health services to take a more grown-up, collaborative approach to care, we need to relinquish some of our statutory power and provide the people we are supposed to be helping with greater safeguards over what does and does not happen to them when they’re unwell.
Photo by Guillaume LORAIN on Unsplash
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