537879 research-article2014
APY0010.1177/1039856214537879Australasian PsychiatryLenagh-Glue et al.
Australasian
Psychiatry
Ethics
When the mandatory second opinion fails to approve compulsory treatment
Australasian Psychiatry 2014, Vol 22(4) 337–340 © The Royal Australian and New Zealand College of Psychiatrists 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1039856214537879 apy.sagepub.com
Jessie Lenagh-Glue Research Assistant, Faculty of Law, University of Otago, Dunedin, New Zealand Paul Glue Professor, Department of Psychological Medicine, University of Otago, Dunedin, New Zealand John Dawson Professor, Faculty of Law, University of Otago, Dunedin, New Zealand
Abstract Objectives: To examine situations in which compulsory treatment was not approved by the second opinion required under New Zealand’s Mental Health Act. Methods: Qualitative and quantitative analysis of 11 index cases where full approval of treatment was not given and of 33 matched controls. Results: The reasons for non-approval of treatment were diverse. Following non-approval, intensive consultation occurred, reflecting significant disagreement between clinicians. The process of resolution included discharge from the Act, patients consenting to treatment and alternative treatment plans. Compared with controls, index cases had significantly lower rates of being mentally well in the community over the subsequent year. Conclusions: Non-approval marks a group of patients with very poor clinical outcome. Explicit processes are needed to manage non-approval of compulsory treatment plans. Keywords: compulsory treatment, consensus, disease management, mental state, Mental Health Act, New Zealand law, outcome, second opinion, Second Opinion Psychiatrist
I
n New Zealand (NZ) and England (UK), mental health law requires mandatory peer review, by a Second Opinion Psychiatrist (SOP), of the treatment proposed by the Responsible Clinician (RC) for a compulsory patient, in certain situations. What is to happen when the SOP does not approve the treatment? Does treatment change? Can disagreements be resolved? What is the effect on the patient’s progress? We examined these questions during the first audit ever conducted of NZ’s second opinion scheme.1 We examined 438 cases, at three different centres, in which SOP approval of treatment was sought. Treatment was not approved in 3% of cases and partially approved in 8%, so full approval was withheld in 11% of cases, overall. We then studied in more depth the position of 11 patients at one centre, whose treatment had not been fully approved (the index cases), matching each against three controls whose treatment was approved. We investigated the reasons why approval was not given, the scope of discussion between the clinicians, whether the patient’s treatment changed, and whether patients whose treatment was not approved had different outcomes. While
there are studies and reviews of the equivalent second opinion process in England (UK),2,3 there has been no previously reported follow-up of cases in which treatment was not approved by the SOP. The legal requirement for a second opinion NZ’s requirement for a second opinion is largely copied from England’s Mental Health Act of 1983 (UK). In NZ, when a compulsory patient does not ‘consent in writing’, their treatment must be approved by a second psychiatrist in two main situations: for ‘other’ treatment for mental disorder (usually medication) for longer than 2 months and for electroconvulsive therapy (ECT) (ss 59, 60 Mental Health (Compulsory Assessment and Treatment) Act 1992 (MHA) of NZ). There, the treatment can only proceed when ‘considered to be in the interests Corresponding author: John Dawson, Faculty of Law, University of Otago, PO Box 56, Dunedin, New Zealand. Email: [email protected]
337 Downloaded from apy.sagepub.com at RUTGERS UNIV on June 1, 2015
Australasian Psychiatry 22(4)
of the patient by a psychiatrist (not being the responsible clinician) … appointed… by the Review Tribunal’. This rule does not say the second psychiatrist can veto the treatment proposal. It says ‘a’ second psychiatrist must approve, leaving open the possibility that another second opinion might be sought. In England (UK), in contrast, the MHA Code of Practice says there is ‘no appeal’ from the second psychiatrist’s decision.4
Methods This was a single-centre sub-study, within a larger retrospective audit of written records of second opinions under the MHA,1 approved by the Multi-Region Ethics Committee, the methods of which are fully described elsewhere.1 The full audit was based on a review of second opinion cases at three centres, between 2003 and 2012, selecting the 60 most recent second opinions on ECT at each centre and the two second opinions on medication nearest in time to each ECT case (120). We therefore studied 180 second opinions at this centre for our substudy. In the current study, characteristics and outcomes of 11 index cases where the treatment was not fully approved were analysed qualitatively, and also compared quantitatively with a sample of 33 controls whose treatment was approved, selected from the remaining cohort of 180. Cases were matched for diagnosis, treatment requested, age, sex and year of request, and followed for 12 months from the date of second opinion. Only three case controls were selected for each index case, because we could not match more than three controls with some index cases on the selection criteria. Data were collected on: •• treatment requested and received; •• date of discharge from hospital and MHA; •• further second opinion requests; •• communications between clinicians and administrators of the Act; •• time to readmission; •• number of readmissions; and •• clinical status at 3, 6 and 12 months. Clinical status was defined categorically based on the presence/absence of symptoms and on the location of treatment at the time (hospitalised, unwell in the community, or well in the community). Post-hoc assessment of statistical power for analysis of clinical outcome at 12 months showed there was > 80% statistical power, α = 0.05, with the 44 subjects (Sigmaplot v12.3). Continuous data were analysed using descriptive statistics (mean and standard deviation). Comparison of quantitative data between index cases and control subjects was by Fisher’s Exact, Fisher-Freeman-Halton (FFH) Exact, or independent t-tests.
Results In 7 of 11 index cases, treatment was not approved by the SOP; and in 4 of 11 it was partially approved. For medication, five index patients had a diagnosis of paranoid schizophrenia, and one each had borderline personality disorder and frontal lobe dementia. For ECT, two index patients had a diagnosis of schizoaffective psychosis, and one each had bipolar affective disorder and major depressive disorder. All had prolonged, complex, severe disorders, which generally seemed refractory to treatment. For ECT, all patients were resistant to multiple medications, hospitalised and had severe symptoms, explaining why the RC proposed this treatment. Nine index patients were hospitalised at the time of the second opinion and two were under Community Treatment Orders. Often the psychiatrist who gave the second opinion had treated the patient previously. Points of disagreement In five cases, disagreement concerned use of psychotropic medication, either changing oral to injectable medication or changing the specified drug; while four concerned ECT and two, psychosocial interventions (where the patient should reside). Disagreements between clinicians about medication arose primarily when the patient voiced significant objection. The RCs either requested changes in the antipsychotic prescribed (4 cases) or a new drug (1 case). In response, in three cases the SOP recommended continuing the current medication, and in one case, psychotherapy and if the patient failed to engage, trying different medication. In the fifth, the SOP felt that the patient’s antipathy to compulsory medication outweighed the potential benefit and that the RC should try instead to establish a therapeutic alliance. In two ECT cases, the SOP recommended medication. In the other two, ECT was partially approved, but qualified by suggestions for prior psychometric testing or proceeding only if the patient did not disagree. In all four cases where approval of ECT was initially withheld, it eventually proceeded, when either the patient consented or a further SOP approved. In one case where a psychosocial intervention was not approved, the SOP’s alternative suggestion was rejected by the RC and the patient taken off the MHA. In the other, a trial of a selective serotonin reuptake inhibitor, recommended by the SOP, was prescribed, and the patient was admitted to a dementia unit by his family, as originally planned.
Resolution Resolutions included taking the patient off the MHA (n = 2); following the SOP’s suggestion (n = 5); the patient eventually consenting to the treatment recommended (n = 2); and
338 Downloaded from apy.sagepub.com at RUTGERS UNIV on June 1, 2015
Lenagh-Glue et al.
Table 1. Demographics of Index and Control Groups
Mean Age (SD) Gender Ethnicity Steps taken following second opinion Discussion with clinical team Discussion with RC Discussion with MHA administrator Alternative treatment suggested by SOP
Index (n = 11)
Controls (n = 33)
Statistics
40 (11) 6 m/5 f 10 E, 1 M
43 (12) 20 m/13 f 22 E, 7 M, 3 P, 1 A
Unpaired t; p = 0.59 Fisher; p = 0.74 FFH; p = 0.54
10 (91%) 10 (91%) 7 (64%) 9 (82%)
23 (70%) 20 (61%) 10 (30%) 1 (3%)
Fisher; p = 0.13 Fisher; p = 0.05 Fisher; p = 0.04 Fisher; p < 0.0001
A: Asian; E: European; f: female gender; FFH: Fisher-Freeman-Halton Exact Test; m: male gender; M: Māori; MHA: Mental Health Act; P: Pacific Islander; RC: Responsible Clinician; SOP: second opinion Psychiatrist.
obtaining a further second opinion approving the treatment (n = 2). In one case, four further second opinions were sought, which were ambiguous or contradicted one another. In all index cases, the SOP justified in writing their objections to the treatment plan. Cases generating most correspondence involved the non-approval of ECT. Process In almost all cases where alternative therapies or approaches were suggested there were discussions between the SOP and the treating team, and with the regional administrator of the MHA, a senior psychiatrist. These discussions often reflected significant dissatisfaction or disagreement. Outcome The outcome for the index patients 12 months after the second opinion was generally extremely poor, with 10 of 11 either in hospital (n = 5) or deemed unwell in the community (n = 5). Comparison of index and control cases Demographic data for index cases and controls are shown in Table 1, upper panel. They were not significantly different in age, gender or ethnicity. Use of psychotropic medication was also similar. The steps taken following the second opinion are shown in Table 1, lower panel. For index cases, there were significantly higher rates of consultation with the RC and MHA administrator, and higher rates of suggestions of alternative treatment made by the SOP. No differences were identified between index and control subjects, in the duration or number of hospitalisations in the 12 months after the second opinion, nor in time to discharge after the second opinion.
Table 2 compares the patients’ functional status (a composite assessment reflecting patient location and mental state) at three time points following the second opinion. The most unwell patients were hospitalised; the least unwell were in the community and had reduced levels of symptoms. Significantly worse functional outcomes were identified for the index patients at 3 and 12 months, with a trend toward significance at 6 months. The main differences between index patients and controls was in the proportion living in the community and mentally unwell (higher in the index cases), compared with living in the community and mentally well (higher in the controls).
Discussion This study had a number of novel findings. Nonapproval involves patients severely affected by mental illness, almost all remaining unwell over the next 12 months. The reasons for non-approval are heterogeneous, as are the resolution processes. We found no overriding theme underlying non-approval of compulsory treatment. When the SOP did not uphold or qualified it, intensive consultation occurred. In some cases, the written exchanges exposed significant dissatisfaction or disagreement with the SOP’s decision. Some clarity is required about the mechanisms for reaching consensus between the RC and SOP, and about the role of the MHA administrator. The most recent guidelines suggest that any attempt to obtain a further second opinion should be initiated by that administrator, not the RC.5 In some controversial cases, the second opinion process seemed to be viewed more as a method for achieving consensus on clinical management than a tool to assess whether valid grounds exist to override the patient’s right to refuse treatment. Both interpretations might be viable under the Act. Both index and control cases were severely affected by mental illness; however, there was a statistically robust
339 Downloaded from apy.sagepub.com at RUTGERS UNIV on June 1, 2015
Australasian Psychiatry 22(4)
Table 2. Clinical Status Post-Second Opinion Time post-SO
Cohort
In hospital
Community and unwell Community and well
FFH Statistics
3 months 6 months 12 months
Index Cases Controlsa Index Cases Controlsa Index Cases Controlsa
5 (45.5%) 17 (52%) 4 (36%) 14 (42%) 5 (45.5%) 14 (42%)
5 (45.5%) 3 (9%) 5 (45.5%) 6 (18%) 5 (45.5%) 2 (6%)
p = 0.02
1 (9%) 11 (33%) 2 (18.5%) 11 (33%) 1 (9%) 11 (33%)
p = 0.18 p = 0.04
aNumbers
do not equal 33: Three controls had no information available at 3 and 6 months, and five had no information available at 12 months, post-SO. FFH: Fisher-Freeman-Halton Exact Test; SO: second opinion.
finding that patients with non-approved second opinions had significantly lower rates of being well and having reduced symptoms in the community, at both 3 and 12 months. This suggests that a failure to fully approve treatment identifies a cohort of patients requiring intensive clinical monitoring and management. Because of the clinical complexity of patients with nonapproved treatment plans, a clearly-defined process should be developed to manage these situations. Nonapproval is a relatively rare event, occurring in patients with very poor clinical outcomes. It should be addressed by explicit guidelines. These might recommend a multidisciplinary complex case conference or further review by a senior, independent clinician. The shortcomings of this analysis must be acknowledged. It evaluated a small number of patients. There is a risk of statistical under-powering for detecting subtle differences between index cases and controls. The retrospective data collection was based on clinical notes and it may not reflect all of the interactions that occurred. This would not affect the finding that clinical outcome at 1 year is significantly worse for the index patients. It is possible that replicating this study at other centres would yield different results. A strength was the nested case control design. Statistical analysis showed that control and index patients were well matched demographically for diagnosis, treatment used, age, sex and ethnicity.
In conclusion, this analysis of failure to approve compulsory treatment plans identifies significant themes associated with resolution of the disagreement. Explicit processes are needed to manage this situation, and the study highlights the importance of intensive clinical input for patients with non-approved treatment plans. Funding This research was supported by a grant from the James Hume Memorial Fund of the University of Otago Medical School.
Disclosure The authors declare there is no conflict of interest. The authors alone are responsible for the content and writing of the paper.
References 1. Dawson J, Ellis P, Glue P, Lenagh-Glue J, Goldsmith D and Smith DAR. Mandatory second opinions on compulsory treatment. In: Dawson J and Gledhill K (eds) New Zealand’s Mental Health Act in practice. Wellington: Victoria University Press, 2013, pp. 229–246. 2. Fennell P. Treatment without consent. London: Routledge, 1996. 3. Mental Health Act Commission. Coercion and consent. London: The Stationery Office, 2009. 4. Department of Health.Code of Practice: Mental Health Act 1983. London: The Stationery Office, 2008. 5. Ministry of Health. Guidelines to the Mental Health (Compulsory Assessment and Treatment) Act 1992. Wellington: Ministry of Health, 2012.
340 Downloaded from apy.sagepub.com at RUTGERS UNIV on June 1, 2015
APY0010.1177/1039856214537879Australasian PsychiatryLenagh-Glue et al.
Australasian
Psychiatry
Ethics
When the mandatory second opinion fails to approve compulsory treatment
Australasian Psychiatry 2014, Vol 22(4) 337–340 © The Royal Australian and New Zealand College of Psychiatrists 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1039856214537879 apy.sagepub.com
Jessie Lenagh-Glue Research Assistant, Faculty of Law, University of Otago, Dunedin, New Zealand Paul Glue Professor, Department of Psychological Medicine, University of Otago, Dunedin, New Zealand John Dawson Professor, Faculty of Law, University of Otago, Dunedin, New Zealand
Abstract Objectives: To examine situations in which compulsory treatment was not approved by the second opinion required under New Zealand’s Mental Health Act. Methods: Qualitative and quantitative analysis of 11 index cases where full approval of treatment was not given and of 33 matched controls. Results: The reasons for non-approval of treatment were diverse. Following non-approval, intensive consultation occurred, reflecting significant disagreement between clinicians. The process of resolution included discharge from the Act, patients consenting to treatment and alternative treatment plans. Compared with controls, index cases had significantly lower rates of being mentally well in the community over the subsequent year. Conclusions: Non-approval marks a group of patients with very poor clinical outcome. Explicit processes are needed to manage non-approval of compulsory treatment plans. Keywords: compulsory treatment, consensus, disease management, mental state, Mental Health Act, New Zealand law, outcome, second opinion, Second Opinion Psychiatrist
I
n New Zealand (NZ) and England (UK), mental health law requires mandatory peer review, by a Second Opinion Psychiatrist (SOP), of the treatment proposed by the Responsible Clinician (RC) for a compulsory patient, in certain situations. What is to happen when the SOP does not approve the treatment? Does treatment change? Can disagreements be resolved? What is the effect on the patient’s progress? We examined these questions during the first audit ever conducted of NZ’s second opinion scheme.1 We examined 438 cases, at three different centres, in which SOP approval of treatment was sought. Treatment was not approved in 3% of cases and partially approved in 8%, so full approval was withheld in 11% of cases, overall. We then studied in more depth the position of 11 patients at one centre, whose treatment had not been fully approved (the index cases), matching each against three controls whose treatment was approved. We investigated the reasons why approval was not given, the scope of discussion between the clinicians, whether the patient’s treatment changed, and whether patients whose treatment was not approved had different outcomes. While
there are studies and reviews of the equivalent second opinion process in England (UK),2,3 there has been no previously reported follow-up of cases in which treatment was not approved by the SOP. The legal requirement for a second opinion NZ’s requirement for a second opinion is largely copied from England’s Mental Health Act of 1983 (UK). In NZ, when a compulsory patient does not ‘consent in writing’, their treatment must be approved by a second psychiatrist in two main situations: for ‘other’ treatment for mental disorder (usually medication) for longer than 2 months and for electroconvulsive therapy (ECT) (ss 59, 60 Mental Health (Compulsory Assessment and Treatment) Act 1992 (MHA) of NZ). There, the treatment can only proceed when ‘considered to be in the interests Corresponding author: John Dawson, Faculty of Law, University of Otago, PO Box 56, Dunedin, New Zealand. Email: [email protected]
337 Downloaded from apy.sagepub.com at RUTGERS UNIV on June 1, 2015
Australasian Psychiatry 22(4)
of the patient by a psychiatrist (not being the responsible clinician) … appointed… by the Review Tribunal’. This rule does not say the second psychiatrist can veto the treatment proposal. It says ‘a’ second psychiatrist must approve, leaving open the possibility that another second opinion might be sought. In England (UK), in contrast, the MHA Code of Practice says there is ‘no appeal’ from the second psychiatrist’s decision.4
Methods This was a single-centre sub-study, within a larger retrospective audit of written records of second opinions under the MHA,1 approved by the Multi-Region Ethics Committee, the methods of which are fully described elsewhere.1 The full audit was based on a review of second opinion cases at three centres, between 2003 and 2012, selecting the 60 most recent second opinions on ECT at each centre and the two second opinions on medication nearest in time to each ECT case (120). We therefore studied 180 second opinions at this centre for our substudy. In the current study, characteristics and outcomes of 11 index cases where the treatment was not fully approved were analysed qualitatively, and also compared quantitatively with a sample of 33 controls whose treatment was approved, selected from the remaining cohort of 180. Cases were matched for diagnosis, treatment requested, age, sex and year of request, and followed for 12 months from the date of second opinion. Only three case controls were selected for each index case, because we could not match more than three controls with some index cases on the selection criteria. Data were collected on: •• treatment requested and received; •• date of discharge from hospital and MHA; •• further second opinion requests; •• communications between clinicians and administrators of the Act; •• time to readmission; •• number of readmissions; and •• clinical status at 3, 6 and 12 months. Clinical status was defined categorically based on the presence/absence of symptoms and on the location of treatment at the time (hospitalised, unwell in the community, or well in the community). Post-hoc assessment of statistical power for analysis of clinical outcome at 12 months showed there was > 80% statistical power, α = 0.05, with the 44 subjects (Sigmaplot v12.3). Continuous data were analysed using descriptive statistics (mean and standard deviation). Comparison of quantitative data between index cases and control subjects was by Fisher’s Exact, Fisher-Freeman-Halton (FFH) Exact, or independent t-tests.
Results In 7 of 11 index cases, treatment was not approved by the SOP; and in 4 of 11 it was partially approved. For medication, five index patients had a diagnosis of paranoid schizophrenia, and one each had borderline personality disorder and frontal lobe dementia. For ECT, two index patients had a diagnosis of schizoaffective psychosis, and one each had bipolar affective disorder and major depressive disorder. All had prolonged, complex, severe disorders, which generally seemed refractory to treatment. For ECT, all patients were resistant to multiple medications, hospitalised and had severe symptoms, explaining why the RC proposed this treatment. Nine index patients were hospitalised at the time of the second opinion and two were under Community Treatment Orders. Often the psychiatrist who gave the second opinion had treated the patient previously. Points of disagreement In five cases, disagreement concerned use of psychotropic medication, either changing oral to injectable medication or changing the specified drug; while four concerned ECT and two, psychosocial interventions (where the patient should reside). Disagreements between clinicians about medication arose primarily when the patient voiced significant objection. The RCs either requested changes in the antipsychotic prescribed (4 cases) or a new drug (1 case). In response, in three cases the SOP recommended continuing the current medication, and in one case, psychotherapy and if the patient failed to engage, trying different medication. In the fifth, the SOP felt that the patient’s antipathy to compulsory medication outweighed the potential benefit and that the RC should try instead to establish a therapeutic alliance. In two ECT cases, the SOP recommended medication. In the other two, ECT was partially approved, but qualified by suggestions for prior psychometric testing or proceeding only if the patient did not disagree. In all four cases where approval of ECT was initially withheld, it eventually proceeded, when either the patient consented or a further SOP approved. In one case where a psychosocial intervention was not approved, the SOP’s alternative suggestion was rejected by the RC and the patient taken off the MHA. In the other, a trial of a selective serotonin reuptake inhibitor, recommended by the SOP, was prescribed, and the patient was admitted to a dementia unit by his family, as originally planned.
Resolution Resolutions included taking the patient off the MHA (n = 2); following the SOP’s suggestion (n = 5); the patient eventually consenting to the treatment recommended (n = 2); and
338 Downloaded from apy.sagepub.com at RUTGERS UNIV on June 1, 2015
Lenagh-Glue et al.
Table 1. Demographics of Index and Control Groups
Mean Age (SD) Gender Ethnicity Steps taken following second opinion Discussion with clinical team Discussion with RC Discussion with MHA administrator Alternative treatment suggested by SOP
Index (n = 11)
Controls (n = 33)
Statistics
40 (11) 6 m/5 f 10 E, 1 M
43 (12) 20 m/13 f 22 E, 7 M, 3 P, 1 A
Unpaired t; p = 0.59 Fisher; p = 0.74 FFH; p = 0.54
10 (91%) 10 (91%) 7 (64%) 9 (82%)
23 (70%) 20 (61%) 10 (30%) 1 (3%)
Fisher; p = 0.13 Fisher; p = 0.05 Fisher; p = 0.04 Fisher; p < 0.0001
A: Asian; E: European; f: female gender; FFH: Fisher-Freeman-Halton Exact Test; m: male gender; M: Māori; MHA: Mental Health Act; P: Pacific Islander; RC: Responsible Clinician; SOP: second opinion Psychiatrist.
obtaining a further second opinion approving the treatment (n = 2). In one case, four further second opinions were sought, which were ambiguous or contradicted one another. In all index cases, the SOP justified in writing their objections to the treatment plan. Cases generating most correspondence involved the non-approval of ECT. Process In almost all cases where alternative therapies or approaches were suggested there were discussions between the SOP and the treating team, and with the regional administrator of the MHA, a senior psychiatrist. These discussions often reflected significant dissatisfaction or disagreement. Outcome The outcome for the index patients 12 months after the second opinion was generally extremely poor, with 10 of 11 either in hospital (n = 5) or deemed unwell in the community (n = 5). Comparison of index and control cases Demographic data for index cases and controls are shown in Table 1, upper panel. They were not significantly different in age, gender or ethnicity. Use of psychotropic medication was also similar. The steps taken following the second opinion are shown in Table 1, lower panel. For index cases, there were significantly higher rates of consultation with the RC and MHA administrator, and higher rates of suggestions of alternative treatment made by the SOP. No differences were identified between index and control subjects, in the duration or number of hospitalisations in the 12 months after the second opinion, nor in time to discharge after the second opinion.
Table 2 compares the patients’ functional status (a composite assessment reflecting patient location and mental state) at three time points following the second opinion. The most unwell patients were hospitalised; the least unwell were in the community and had reduced levels of symptoms. Significantly worse functional outcomes were identified for the index patients at 3 and 12 months, with a trend toward significance at 6 months. The main differences between index patients and controls was in the proportion living in the community and mentally unwell (higher in the index cases), compared with living in the community and mentally well (higher in the controls).
Discussion This study had a number of novel findings. Nonapproval involves patients severely affected by mental illness, almost all remaining unwell over the next 12 months. The reasons for non-approval are heterogeneous, as are the resolution processes. We found no overriding theme underlying non-approval of compulsory treatment. When the SOP did not uphold or qualified it, intensive consultation occurred. In some cases, the written exchanges exposed significant dissatisfaction or disagreement with the SOP’s decision. Some clarity is required about the mechanisms for reaching consensus between the RC and SOP, and about the role of the MHA administrator. The most recent guidelines suggest that any attempt to obtain a further second opinion should be initiated by that administrator, not the RC.5 In some controversial cases, the second opinion process seemed to be viewed more as a method for achieving consensus on clinical management than a tool to assess whether valid grounds exist to override the patient’s right to refuse treatment. Both interpretations might be viable under the Act. Both index and control cases were severely affected by mental illness; however, there was a statistically robust
339 Downloaded from apy.sagepub.com at RUTGERS UNIV on June 1, 2015
Australasian Psychiatry 22(4)
Table 2. Clinical Status Post-Second Opinion Time post-SO
Cohort
In hospital
Community and unwell Community and well
FFH Statistics
3 months 6 months 12 months
Index Cases Controlsa Index Cases Controlsa Index Cases Controlsa
5 (45.5%) 17 (52%) 4 (36%) 14 (42%) 5 (45.5%) 14 (42%)
5 (45.5%) 3 (9%) 5 (45.5%) 6 (18%) 5 (45.5%) 2 (6%)
p = 0.02
1 (9%) 11 (33%) 2 (18.5%) 11 (33%) 1 (9%) 11 (33%)
p = 0.18 p = 0.04
aNumbers
do not equal 33: Three controls had no information available at 3 and 6 months, and five had no information available at 12 months, post-SO. FFH: Fisher-Freeman-Halton Exact Test; SO: second opinion.
finding that patients with non-approved second opinions had significantly lower rates of being well and having reduced symptoms in the community, at both 3 and 12 months. This suggests that a failure to fully approve treatment identifies a cohort of patients requiring intensive clinical monitoring and management. Because of the clinical complexity of patients with nonapproved treatment plans, a clearly-defined process should be developed to manage these situations. Nonapproval is a relatively rare event, occurring in patients with very poor clinical outcomes. It should be addressed by explicit guidelines. These might recommend a multidisciplinary complex case conference or further review by a senior, independent clinician. The shortcomings of this analysis must be acknowledged. It evaluated a small number of patients. There is a risk of statistical under-powering for detecting subtle differences between index cases and controls. The retrospective data collection was based on clinical notes and it may not reflect all of the interactions that occurred. This would not affect the finding that clinical outcome at 1 year is significantly worse for the index patients. It is possible that replicating this study at other centres would yield different results. A strength was the nested case control design. Statistical analysis showed that control and index patients were well matched demographically for diagnosis, treatment used, age, sex and ethnicity.
In conclusion, this analysis of failure to approve compulsory treatment plans identifies significant themes associated with resolution of the disagreement. Explicit processes are needed to manage this situation, and the study highlights the importance of intensive clinical input for patients with non-approved treatment plans. Funding This research was supported by a grant from the James Hume Memorial Fund of the University of Otago Medical School.
Disclosure The authors declare there is no conflict of interest. The authors alone are responsible for the content and writing of the paper.
References 1. Dawson J, Ellis P, Glue P, Lenagh-Glue J, Goldsmith D and Smith DAR. Mandatory second opinions on compulsory treatment. In: Dawson J and Gledhill K (eds) New Zealand’s Mental Health Act in practice. Wellington: Victoria University Press, 2013, pp. 229–246. 2. Fennell P. Treatment without consent. London: Routledge, 1996. 3. Mental Health Act Commission. Coercion and consent. London: The Stationery Office, 2009. 4. Department of Health.Code of Practice: Mental Health Act 1983. London: The Stationery Office, 2008. 5. Ministry of Health. Guidelines to the Mental Health (Compulsory Assessment and Treatment) Act 1992. Wellington: Ministry of Health, 2012.
340 Downloaded from apy.sagepub.com at RUTGERS UNIV on June 1, 2015
