Saturday, March 21, 2009

On Being Your Patients' Keeper

Sexy psych nurse Mr. Ian of MentalNurse wonders why "risk assessment" (for harm to others) is the exclusive province of mental health professionals, to the exclusion of other specialties. Medical patients other than mental patients often pose a risk to other people - but doctors and other health care workers are not expected to police them. Whose risk is it, anyway? He says:
Who says it’s my responsiblity to assess, manage and mitigate risk of harm to others?

I could flip the question - why is risk assessment and management only an obligation of the mental health sector?

Why aren’t parole boards required to meet the same standard when releasing a known violent person? They don’t even have an obligation to the offender. Their obligation is to the safety of the public.

Why can’t opticians remove someone’s license to drive when they’ve failed an eye test or GPs remove licenses from those with ‘at risk’ medical conditions? Why aren’t these people risk assessed and arrested if they fail the eye test but found driving a car?

I think the same questions can be asked for risk assessment focusing on "danger to self."

11 comments:

  1. Mr Ian, our correspondent from Australia, is indeed sexy.

    My own Nuremberg defence on risk assessing somebody's risk to themselves is what I think of as my "you'll thank me in the morning" defence.

    If I was to go out with a bunch of friends and got so heavily drunk that I started picking a fight with a stranger, or playing chicken with moving cars, or dangling myself from the safety raiil of a bridge, then I'd hope that my friends would have the decency to stop me, then put me a taxi and take me home rather than stand and watch letting me get on with it. In the morning when I've sobered up I'd consider them true friends for doing the former rather than the latter.

    (No, this is not what I'm normally like on a night out. It's an analogy.) :p

    In the same vein, if somebody is in the grip of a psychotic, depressive or manic episode, the assumption that they'll Thank Me In The Morning - or at least when they come out of this particular episode - for not letting them harm themselves.

    Admittedly that does mean I'm making an assumption on their part, but in today's social, political and legal climate, assumptions have to err on the side of keeping people safe.

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  2. I think there's something to be said for the "intervene if the person will thank you in the morning" strategy. But why should that only apply to psych patients, and not other patients?

    Many people struggle with obesity and its health consequences. Why don't GPs lock them up in a hospital when they weigh too much (or can't control their diabetes)?

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  3. I suppose the main differences with obesity is (a) the immediate and grave risk to life - getting fat isn't good for you, but a bacon sandwich won't kill you there and then - and (b) the issue of impaired mental capacity.

    My own experience of suicide attempts is that they nearly always take place in the context of some sort of crisis, and often under the influence of alcohol or drugs. One doesn't usually see someone calmly, rationally make a considered choice to end their lives.

    I suspect that someone who did so probably wouldn't come to the attention to pschiatric services anyway. They'd be more likely to go off quietly somewhere and just do it.

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  4. What I would like to push on is the idea of "impaired mental capacity." Many activities - becoming obese, engaging in unprotected sex with lots of strangers, smoking cigarettes, fighting in a bar - are pretty clearly not rational, in that they are caused by biological factors we have very little conscious control over. Yet we rarely treat such actions as the result of "impaired mental capacity." Deliberate self-harm is seen as evidence of "impaired mental capacity," whereas reckless or merely stupid self-harm is not, however dangerous it may be. If we look at things through the lens of autonomy, the opposite policy would seem to make more sense - if people really want to hurt themselves, let them, but if they don't want to hurt themselves but are too weak-willed to avoid it, we should intervene.

    It's similar to the different ways people are treated when they refuse necessary medical care. If they refuse care because of a religious belief, imagining that a magical sky god will perform a miracle and save them or at least reward them for refusing a blood transfusion, we do not interfere. But when a patient under no such delusion refuses necessary medical care because he wants to die, he is much more likely to be found incompetent and his decision taken from him.

    About your last paragraph, sometimes it works that way, sometimes it doesn't:

    Woman wounded in apparent suicide try

    A woman was found shot in the head in West Baltimore yesterday afternoon in an apparent suicide attempt, said police spokeswoman Nicole Monroe. The woman was found at Edgemont and Parkwood avenues about 12:51 p.m., Monroe said. The woman, whose name was not released, survived the shooting, Monroe said last night, but her condition was unavailable.

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  5. I'm not sure I agree with someone who is a smoker having "impared mental capacity". Being addicted to something is not necessarily a refection of poor mental health, or suffering loss of touch with reality.

    Perhaps a different set of priorities are in place to a non-smoker, but surely not a mental health issue. Is that not covered by the clause of being able to fully understand the consequences of their actions? I'm not sure that smoking comes with the same agnosognosia as other true mental health conditions.

    Lola x
    (Smoker)

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  6. Thanks Lola. I agree that smoking (and the other behaviors I mention above) aren't properly considered mental illnesses. My point is that there are many dangerous behaviors that are not strictly under rational control, and which a person might very much wish to stop, that are not products of mental illness, and I see no underlying rationale for intervention only in the case where the behavior is caused by a mental illness rather than an ordinary lack of rational control.

    I wish to suggest that the distinction (between self-harming behavior caused by a mental illness and irrational self-harming behavior caused by other factors) is more definitional than actually supportable.

    (Also, I don't mean to suggest that smoking and the other behaviors I list are always irrational.)

    Agnosognosia - I had to look that up; for non-medical folks, it means lack of insight (caused by the underlying condition). That could be a very useful tool in evaluating whether it is morally correct to intervene. (It would seem to be a feature of not only many mental illnesses, but behaviors like joining a cult.)

    Not all mental illnesses come with lack of insight, though. Also, the level of appreciation of risk varies with my list of dangerous behaviors, and at least some of them may be self-reinforcing in the "lack of insight" sense. Lack of insight is a classic (perhaps cliched) symptom of alcoholism. And each instance of performing any dangerous, provocative behavior causes the actor to adjust to seeing the behavior as less serious. (Not to mention social effects, especially for obesity.)

    I really appreciate the thoughtful comments, guys.

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  7. ...lack of insight (caused by the underlying condition)

    It's so tempting to track back on this -- to the human condition.

    I don't mean to disrupt a thoughtful conversation, but it's difficult for me to imagine ANY choice being perfectly insightful. Excepting cases where a danger is posed to others, I think interventions are most meaningfully grounded in disapproval. In a given institutional setting, disapproval may be couched in professional argot. In interpersonal relations, it's more often about concern over the welfare of a friend or loved one who might know better but for x. The problem is, there's always an x.

    The paternalistic conceit becomes clearer when the self-harmful behavior to be thwarted falls within socially nebulous limits (as with smoking, alcoholism, overeating), but I start with the assumption that the interventionist impulse is always violative. I'm not saying it's always wrong; I just don't think there's a clear way to demarcate this stuff without begging hard questions about the value of autonomy.

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  8. @Chip

    I start with the assumption that the interventionist impulse is always violative. I'm not saying it's always wrong; I just don't think there's a clear way to demarcate this stuff without begging hard questions about the value of autonomy.

    As I'm in the UK, these kinds of decisions are generally demarcated by the Mental Capacity Act. Personally I think the key principles make for a simple yet quite elegant framework for deciding whether it's right to make a decision on behalf of another adult. These five principles are:

    - A person must be assumed to have capacity unless it is established that he lacks capacity.

    - A person is not to be treated as unable to make a decision unless all practicable steps to help him to do so have been taken without success.

    - A person is not to be treated as unable to make a decision merely because he makes an unwise decision.

    - An act done, or decision made, under this Act for or on behalf of a person who lacks capacity must be done, or made, in his best interests.

    - Before the act is done, or the decision is made, regard must be had to whether the purpose for which it is needed can be as effectively achieved in a way that is less restrictive of the person’s rights and freedom of action.


    I'm particularly fond of the third one, since it enshrines in law that we have the right to make unwise decisions - to smoke, to eat fatty foods, to drink too much etc.

    The Mental Capacity Act wouldn't be used to decide whether somebody could commit suicide (that comes under the Mental Health Act), but you might use it to decide whether one could e.g. impose a healthy eating plan on someone. (Could you do it if they had no cognitive impairment and fully understood that fatty foods are bad for you? How about if they have a severe learning disability and are diabetic and hypertensive?)

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  9. The Mental Capacity Act wouldn't be used to decide whether somebody could commit suicide

    I beg to differ.

    MCA will be the reference point for voluntary euthanasia eventually. There is no MHA in terminal cancer etc.

    If someone is able to make a rational decision then that includes life or death.
    If their capacity is in question by virtue of ?MI - then, just as the MCA - or is it the Aussie version? - says - decisions made by others on their behalf must be in keeping with the persons general beliefs etc.

    So if I knew you'd been suicidal for 10 years - then went into a coma after a botched job - and I was called to make the decision on your behalf of 2 years and a possible full recovery (or any manner of vegetative state) - or cease life support ... as long as I thought I knew you well enough - I'd tell them to pull the plug - it's what you'd want.

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  10. I can't say how much I respect that. It's the proper course.

    The opposite is often true in American medicine. Folks who end up with akinetic mutism secondary to a suicide attempt end up guinea pigs in teaching hospitals, despite their clearly manifested wish to die. The fact that suicide was attempted at all destroys any possible finding of "competency," hence any legal effect of an advance directive refusing care.

    Mr. Ian has it right - for a consistently suicidal person who enters a coma after a "botched job," the right thing to do is to let him die.

    It seems obvious, but it's by no means the law of many lands at all. Certainly not my land.

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