psy chi at ric hos pi tals in On tario who ap plied for a re view of a find ing of treat ment ... om mend that treat ment not be im peded once a re view board has con ...
Original Research
Treatment Delays for Involuntary Psychiatric Patients Associated With Reviews of Treatment Capacity Michelle Kelly, MD, FRCPC 1, San dra Dunbar2 , John E Gray, PhD 3, 4 Rich ard L O’Reilly, MB, FRCPC Objective: To de ter mine the du ra tion of de lays in treat ment ini tia tion when in vol un tary pa tients ap ply for a re view of a find ing of treat ment in ca pac ity and to es ti mate the cost of keep ing pa tients hos pi tal ized with out treat ment in these cir cum stances. Method: Us ing a com put er ized da ta base and writ ten records, we iden ti fied all pa tients at 2 psychiatric hos pi tals in On tario who ap plied for a re view of a find ing of treat ment in ca pacity dur ing a 10- year pe riod. We re corded clini cal and demo graphic vari ables, dates of stopping and start ing medi ca tion, and dates of re view board hear ings and out comes. We also noted all cases in which a pa tient ap pealed a de ci sion from the re view board to the court. Results: Two hun dred and thirty- seven pa tients made 334 ap pli ca tions to the re view board. The board over turned the phy si ci an’s find ing of in ca pac ity in only 5 (1.5%) ap pli ca tions; 15 ap pealed the re view board’s find ing to the courts. None of these ap peals were suc cess ful. In the ab sence of an ap peal to the courts, the av er age de lay in ini ti at ing treat ment w as 25 days. For pa tients ap peal ing to the court, the av er age de lay was 253 days. The cost of hos pi tal iz ing un treated pa tients while their ca pac ity was un der le gal re view was es ti m ated at $3 867 000, of which $1 333 000 could have been saved if treat ment had started im me diately af ter the re view board con firmed in ca pac ity. Conclusion:We have identified ex ten sive de lays in ini ti at ing psy chi at ric treat ment for a number of pa tients. These de lays are as so ci ated with le gal re view of treat ment ca pac ity. There are se ri ous clini cal risks and sub stan tial costs as so ci ated with de lay in treat ing pa tients with acute psy chi at ric ill ness. Where ju ris dic tions re view treat ment ca pac ity, we recom mend that treat ment not be im peded once a re view board has con firmed a clini cal find ing of in ca pac ity. (Can J Psy chia try 2002;47:181–185)
Clini cal Im pli ca tions • Men tal health leg is la tion in some Ca na dian ju ris dic tions re sults in un ac cept able de lays in ini tiat ing stan dard psy chi at ric treat ment. • There is a sig nifi cant fi nan cial cost and poor use of scarce psy chi at ric beds, in ad di tion to previ ously re ported ad verse clini cal out comes. • Leg is la tors need to con sider clini cal out comes and costs when draft ing men tal health leg is lation. Limitations • The study only looked at pa tients who ap pealed treat ment in ca pac ity. • The study meth ods did not al low for a sys tem atic evalua tion of clini cal out comes as so ci ated with treat ment de lay.
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Key Words: mental health legislation, treatment capacity, treatment incapacity, treatment competency, treatment delay n most Canadian jurisdictions, a physician determines whether a patient is ca pa ble of con sent ing to psy chi at ric treat ment; in some ju ris dic tions, treat ment re fusal is not per mit ted (1). In those ju ris dic tions that al low treat ment re fusal, pa tients can chal lenge a find ing of in ca pac ity by ap ply ing to a quasi-judicial re view board, and the de ci sions of the re view board can be fur ther ap pealed to the courts. If an ap pli ca tion to a re view board is ini ti ated and treat ment has not al ready com menced, it can not be gin un til the mat ter is re solved. As a re sult of this legal requirement, patients are sometimes detained with out treat ment for ex tended pe ri ods.
I
De layed psy chi at ric treat ment of de tained pa tients has been linked to sev eral se ri ous harms. These in clude pro longed in dividual suffering, in creased self-destructive behaviour, in creased use of seclusion and restraint, poorer long-term prog no sis, de te ri o ra tion of the ther a peu tic al li ance, in creased as saults by the pa tient, cre ation of a nontherapeutic ward mi lieu, de mor al iza tion and eth i cal di lem mas for health pro fes sion als, the block ing of in pa tient beds, re di rec tion of lim ited clin i cal re sources to nontherapeutic ac tiv i ties and, par a dox i cally, the de pri va tion of lib erty rights that re sults from with holding the treatment nec es sary to ef fect re lease from in vol un tary de ten tion. De tailed ev i dence for these det ri men tal effects of treat ment de lay has been re viewed else where (1,2). In the US, sev eral stud ies have ex am ined the amount of time elaps ing be tween the on set of treat ment re fusal and the dis po si tion of the mat ter by the courts (3–6). De lays in ini ti at ing treat ment mea sured in this way range from a low of 24 days (4) to a high of 135 days (3). In Can ada, there are sin gle case re ports of a man with ac tive schizo phre nia and a his tory of good clin i cal re sponse to antipsychotic med i ca tion who was de tained un treated for nearly 2 years (7), and of an other man with an ac tive psy chotic ill ness who was kept, un treated and in se clu sion, for over 404 days (8). We are un aware of any sys tem atic re search on the du ra tion of treat ment de lays car ried out in a Ca na dian ju ris dic tion. Thus, our ob jec tive in this study was to de ter mine the du ra tion of de lays in ini ti at ing treat ment for pa tients found to be in ca pa ble of con sent ing to psy chi at ric treat ment at 2 On tario psy chi at ric hospitals. We also calculated the resulting financial cost. While we noted some neg a tive out comes as so ci ated with pro longed de lays in ini ti at ing treat ment, we were un able to sys tematically ex am ine clin i cal out comes in this study. 182
Method We con ducted the study at Lon don Psy chi at ric Hos pi tal and St Thomas Psychiatric Hos pital, both located in southwestern Ontario. The Ministry of Health op er ated both hos pi tals as sep a rate en ti ties be fore they were placed un der joint ad min istra tion in 1995. Dur ing the 10-year pe riod of the study (Jan uary 1, 1990, to De cem ber 31, 1999), the hos pi tals ex pe ri enced a pro gres sive de cline in the num ber of in pa tient beds (from 388 at Lon don and 355 at St Thomas at the be gin ning of the study to 338 and 245, re spec tively, at its end). A to tal of 22 284 ad mis sions oc curred dur ing the study, of which 4444 (20%) were in vol un tary. The Clin i cal In for ma tion De part ment at each hos pi tal maintained a re cord of all ap pli ca tions to the Con sent and Ca pac ity Board (CCB), for merly known as the On tario Re view Board. One of us ex am ined the charts of all pa tients who ap plied to the CCB dur ing the study pe riod. In for ma tion ex tracted from chart re view in cluded the dates of ad mis sion, dis charge, de termi na tion of treat ment in ca pac ity, re fusal of treat ment, ap plication to the CCB, CCB hearing, and date of treatment ini ti a tion where the CCB up held a find ing of in ca pac ity. In addi tion, we re corded de mo graphic data and dis charge di ag noses. Finally, if pa tients had ap pealed to the courts, we re corded the date the ap peal was ini ti ated, date of the court hear ing, and the date of treat ment ini ti a tion if the court con firmed in ca pacity. From these data, we were able to cal cu late the du ra tion of de lay in ini ti at ing treat ment, de fined as the time be tween a patient’s re fusal of rec om mended treat ment and the time when treat ment was started or reinitiated.
Results Dur ing the 10-year study pe riod, 237 pa tients made a to tal of 334 ap pli ca tions to the CCB. In all cases, the con tested ca pacity re lated to treat ment with med i ca tion rather than to other treat ment mo dal i ties. Forty-nine pa tients ap plied to the CCB more than once dur ing the study, with 1 pa tient mak ing 11 appli ca tions. Un less in di cated, all sub se quent anal y ses that we dis cuss are on ap pli ca tions, not pa tients. Ap pli ca tions were evenly di vided be tween men and women pa tients (169 and 165, re spec tively). The av er age age of a pa tient mak ing an application was 42 years (range, 16 to 81). All pa tients were diag nosed with a psy chotic dis or der (Ta ble 1). We were un able to as cer tain the to tal num ber of pa tients found to be treat ment-incapable dur ing the full study pe riod, because a re cord of all de ter mi na tions of in ca pac ity was only kept for the years 1998 and 1999. In those 2 years, how ever, there were 252 in stances wherein a pa tient was found to be treat ment in ca pa ble. Of these, 52 (21%) were ap pealed to the CCB. W Can J Psy chia try, Vol 47, No 2, March 2002
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Table 1. Diagnoses of patients applying for a consent and capacity board (CCB) hearing Diagnosis
Frequency
%
Schizophrenia
150
44 .9
Schizoaffective disorder
60
18 .0
Bipolar disorder- manic
80
24 .0
Delusional disorder
12
3 .6
Other psychosis
32
9 .6
Total
334
100 .0
Table 2. Outcome of CCB hearings Outcome
Num ber
%
Withdrawn by patient
76
22 .8
Dismissed without hearing
9
2 .7
Reassessed as capable by physician
12
3 .6
Confirmed by CCB
232
69 .5
5
1 .5
Found capable by CCB Total
In the 10-year sample, incapacity was de ter mined within 1 week of the pa tient’s ad mis sion, while in 131 cases the pa tient was de ter mined in ca pa ble 1 month or more af ter ad mis sion. In 4 cases, the pa tient had been found treat ment in ca pa ble prior to ad mis sion. An av er age of 7.5 days (range, 1 to 59) elapsed be tween a pa tient’s ap pli ca tion for a re view and the ini tial hear ing. The On tario Health Care Con sent Act stip u lates that this must oc cur within 1 week (9). It was clear from the chart re views that de lays of ten oc curred be cause of a re quest for ad journ ment by one of the par ties or be cause the CCB ad journed to con sider whether an ap pli ca tion was valid. Ta ble 2 shows the dis po si tion of the 334 ap pli ca tions. The re view board over turned a find ing of treat ment in ca pac ity in 5 (1.5%) ap pli ca tions. In 7 cases the CCB con firmed the find ing that the pa tient was in ca pa ble of con sent ing to treat ment but also found that the pa tient did not meet the cri te ria for in vol un tary admission. These 7 patients discharged themselves against med i cal ad vice and were not treated. Be fore we de scribe the length of treat ment de lays, it is im por tant to note that the On tario Health Care Con sent Act is writ ten in a way that clearly pro hib its the ini ti a tion of treat ment if a pa tient ap plies for a CCB hear ing or ap peals to the court. The Act is usu ally, how ever, in ter preted as per mit ting treat ment con tin u a tion while the is sue is be fore the board or courts. We iden ti fied 38 cases (out of 334) where pa tients con tin ued to re ceive med i ca tion while the CCB con sid ered their cases. None W Can J Psy chia try, Vol 47, No 2, March 2002
334
100.0
of the pa tients who ap pealed to the courts re ceived med i ca tion dur ing their ap peal. Where pa tients ap plied to a re view board but did not pur sue an ap peal to the court, the av er age de lay in treat ment ini ti a tion was 25 days from the date of treatment re fusal (range, 3 to 277). The pa tients who con tin ued to re ceive treat ment were ex cluded from this anal y sis. The cases at the up per end of the range of de lays oc curred when the pa tient was ei ther not declared treat ment-incapable for some time af ter re fus ing treatment or not treated for an ex tended pe riod af ter a CCB hear ing con firmed in ca pac ity. In 142 cases, the find ing of in ca pac ity was made within 1 week of the pa tient dis con tinu ing treatment, whereas in 19 cases it was made more than 1 month af ter the pa tient re fused treat ment. More over, while in 140 cases treat ment was re started within the week af ter the CCB up held the find ing of in ca pac ity, in 6 cases treat ment was not restarted for more than 1 month af ter the CCB ren dered its de cision. There were various rea sons for these delays. For ex am ple, in some cases the sub sti tute de ci sion maker re fused to con sent to the rec om mended treatment. In the 10-year study pe riod, 15 pa tients ap pealed the CCB’s con fir ma tion of in ca pac ity to the courts. Only 8 of these 15 patients ac tu ally had a court hear ing. Three pa tients with drew their ap peal to the courts and ac cepted treat ment, 2 ab sconded from the hos pi tal, and 2 were found to no lon ger meet the criteria for involuntary ad mission and promptly discharged them selves against med i cal ad vice. The courts con firmed the 183
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find ing of in ca pac ity in all 8 cases it heard. Thus, 11 of the 15 pa tients who ap pealed to the courts were even tu ally treated, the av er age de lay in ini ti at ing treat ment for these 11 pa tients be ing 253 days (range 55 to 721). One pa tient who left against med i cal ad vice killed him self by self-evisceration shortly af ter leav ing hos pi tal. We cal cu lated the cost of pro vid ing hos pi tal iza tion while not treat ing pa tients based on a hos pi tal per diem cost of $492. The to tal cost was $3 867 000. Hospitalizing pa tients un treated un til the CCB hear ing cost $2 534 000, and it cost $1 333 000 to de tain un treated pa tients in hos pi tal dur ing their ap peal to the courts. These fig ures do not in clude the ad di tional costs of le gal fees and staff time needed to pre pare for and pres ent at re view boards and in court.
Discussion Our data show that it is rel a tively com mon for pa tients to chal lenge a de ter mi na tion of treat ment in ca pac ity. The fi nan cial cost of these chal lenges is sub stan tial. Some peo ple would ar gue that hos pi tal costs are fixed, be cause bed oc cu pancy does not vary greatly, and what is ac tu ally lost by block ing beds is the op por tu nity to treat oth ers in need. We ex am ined the data from this per spec tive, us ing 3 weeks as a typ i cal du ra tion of hos pi tal iza tion for pa tients with an acute psy chotic decompensation. Based on this fig ure, an ad di tional 374 pa tients could have been treated and dis charged if treat ment had pro ceeded dur ing the re view pro cess. Al ter na tively, an ad di tional 129 patients could have been treated, had treatment started once the CCB con firmed in ca pac ity. Faced with these costs and the se ri ous clin i cal con se quences out lined in the in tro duc tion, we must ques tion whether with hold ing treat ment dur ing lengthy ap peals can be jus ti fied from a legal or an ethical perspective. Not permitting treatment while an ap peal is be fore the courts is based on the con cern that some pa tients might re ceive treat ment in ap pro pri ately. If it could be dem on strated that a sub stan tial num ber of pa tients who ap peal treat ment inca pac ity to the ju di cial or quasi-judicial bod ies is suc cess ful, this might go some way to off set ting the risks as so ci ated with treat ment de lays. In our study, only 1.5% were ac tu ally found to be ca pa ble by the CCB, and no pa tient who ap pealed a find ing from the CCB to the courts was found to be ca pa ble. Sev eral stud ies in the US have re ported sim i lar ob ser va tions that courts up hold phy si cians’ findings of treatment incapacity at very high rates (sum ma rized by Applebaum [10]). If treat ment had com menced im me di ately af ter the phy si cian made the de ter mi na tion of in ca pac ity, 5 pa tients would have re ceived treat ment be fore their CCB hear ing found that they were legally capable of refusing treat ment. A fur ther 7 pa tients would have been treated be fore the CCB con firmed their incapacity but stated that they could no longer be 184
de tained as in vol un tary pa tients. In eval u at ing the im por tance of these short pe ri ods of treat ment (1 week on av er age), it is im por tant to ap pre ci ate that ca pa ble pa tients may re fuse treatment that is clin i cally in di cated. A find ing of ca pac ity does not mean that the CCB be lieved that the rec om mended treat ment was clinically in appropriate. In this series, the court con firmed in ca pac ity in all cases it re viewed. Thus, if treat ment had started im me di ately af ter the CCB con firmed in ca pac ity, no pa tient would have been treated and sub se quently found by the courts to have been ca pa ble. How ever, 4 pa tients who evaded treatment because they absconded or dis charged them selves against med i cal ad vice (in clud ing 1 who com mitted sui cide) would have re ceived treat ment. Given the ev i dence of se ri ous harm, we be lieve that pro tracted de lays in treat ment ini ti a tion can not be jus ti fied. Even con sider ing the is sue ex clu sively from a lib er tar ian per spec tive, we see no jus ti fi ca tion for de priv ing in di vid u als of their free dom for pe ri ods of up to 2 years when there is al most no pos si bil ity that they will ul ti mately be judged to be ca pa ble. We pro pose 2 op tions to abol ish or re duce de lays as so ci ated with re views or ap peals. In de pend ent re view re mains available with both op tions—an im por tant check against pos si ble physician error. In the first option, treatment would com mence with the sub sti tute de ci sion maker’s con sent and would con tinue un less a re view board or court found the pa tient to be ca pa ble. This ap proach is anal o gous to re views and ap peals of in vol un tary hos pi tal iza tion, wherein the pa tient is de tained dur ing the pro cess. We note that this op tion has ef fects sim i lar to the men tal health acts of 3 Ca na dian prov inces (Brit ish Colum bia, Sas katch e wan, and New found land) that do not per mit treat ment re fusal for in vol un tary pa tients (1). In the second op tion, when a pa tient chal lenges a find ing of treat ment in capacity, treatment would be delayed un til the review board con firms in ca pac ity. This op tion would sig nif i cantly limit but not erad i cate treat ment de lays be cause it would not elim i nate the possibility of lengthy adjournments of review board hearings. Finally, it is important that physicians, with the support of hos pi tals, use avail able men tal health leg is la tion to en sure opti mum clin i cal treat ment. We note that dur ing the study pe riod nei ther hos pi tal at tempted to use the pro vi sion of the On tario Health Care and Con sent Act that al lows an ap pli ca tion to the courts for an or der to treat a pa tient, pend ing the fi nal dis po sition of the ap peal (9, s. 19). In On tario, the le gal test for granting an in terim treat ment or der is based on best in ter est, with the ad di tional re quire ment that the hos pi tal prove the need to ini ti ate treat ment prior to the fi nal dis po si tion of the ap peal. We sug gest that this ne ces sity can eas ily be ar gued based on the mul ti ple harms as so ci ated with pro longed pe ri ods of un treated psy cho sis (2). W Can J Psy chia try, Vol 47, No 2, March 2002
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2. O’Reilly RL, Kelly M, Dunbar S, Gray JE. Treat ment de layed jus tice de nied: de lays in ini ti at ing treat ment caused by court re view of in ca pac ity. Pa per presented at the XXVIth In ter na tional Con gress on Law and Men tal Health. July 1–6, 2001; Mon treal (QC). 3. Veliz J, James WS. Med i cine court: Rog ers in prac tice. Am J Psy chi a try 1987;144:62–7. 4. DeLand FH, Borenstein NM. Med i cine Court, II: Rivers in prac tice. Am J Psy chi a try 1990;147:38–43. 5. Zito JM, Craig TJ, Wanderling J. New York un der the Rivers de ci sion: an ep i de mi o log i cal study of drug treat ment re fusal. Am J Psy chi a try 1991;148:904–9. 6. Ciccone JR, Tokoli JF, Gift TE, Clements CD. Med i ca tion re fusal and ju di cial ac tiv ism: a re ex am i na tion of the ef fects of the Rivers de ci sion. Hospi tal and Com mu nity Psy chi a try 1993;44:555–60. 7. O’Reilly, RL. Men tal Health Leg is la tion and the right to ap pro pri ate treat ment. Can J Psy chi a try 1998;43:811–5. 8. Sevels v Cameron (1994), OJ 2123 (QL) (Ont Gen Div). 9. Health Care Con sent Act. To ronto: Queen’s Printer for On tario; 1996. 10. Appelbaum PS. Right to re fuse treat ment with med i ca tion: con sent, co er cion, and the courts. In: Appelbaum PS. Al most a rev o lu tion. New York: Ox ford Univer sity Press; 1994. p 114–62.
Conclusion As a re sult of the re view pro cess for treat ment ca pac ity, most patients experience some de lay in the ini ti a tion of stan dard psychiatric treat ment. In this study, we iden ti fied sev eral patients who ex pe ri enced pro tracted treat ment de lays. These delays resulted in un necessary costs, unavailable beds, and di ver sion of staff time—in ad di tion to the pre vi ously de scribed det ri men tal clin i cal out comes. More over, un nec es sary de lays in treat ment ini ti a tion pro long in vol un tary de ten tion and thus, par a dox i cally, de prive pa tients of their lib erty rights un der the Ca na dian Char ter of Rights and Free doms. We have out lined 2 options to reduce these de lays. Leg is la tors should consider clinical outcomes and costs, in addition to legal principles, when draft ing men tal health leg is la tion. Acknowledgements We thank the clin i cal re cords staff of the Lon don and St Thomas Psychi at ric Hos pi tals (now Re gional Men tal Health Care–Lon don and St Thomas) for their as sis tance with re cord re trieval and Ms Mary Taylor for her as sis tance pro duc ing the manu script.
References 1. Gray JE, Shone MA, Liddle PF. Ca na dian men tal health law and pol icy. To ronto; Butterworths Can ada Ltd: 2000.
Manuscript received April 2001, revised, and accepted November 2001. For merly, Psy chi at ric Res i dent, De part ment of Psy chi a try, The Uni ver sity of West ern On tario, Lon don, On tario; now, pri vate prac tice, Lon don, Ontario. 2 Re search and Ed u ca tion As sis tant, Re search and Ed u ca tion Unit, Re gional Men tal Health Care, St Jo seph’s Health Care, Lon don, On tario. 3 Man ager, Pol icy and Sys tems De vel op ment, Adult Men tal Health Di vi sion, Min is try of Health, Vic to ria, Brit ish Co lum bia. 4 As so ci ate Pro fes sor, De part ment of Psy chi a try, The Uni ver sity of West ern On tario, Lon don, On tario. Ad dress for cor re spon dence: Dr RL O’Reilly, Co or di na tor, Re search and Ed u ca tion Unit, Re gional Men tal Health Care, Lon don, PO Box 5532, Station B 850 High bury Av e nue North, Lon don, ON N6A 4H1 1
Rés umé : Délais de traitement des patients psychiatriques en cure obligatoire, associés aux évaluations de l’aptitude au traitement Ob jec tif : Dé ter mi ner la du rée des dé lais du dé but du traite ment quand les pa tients en cure ob li gatoire de man dent une évalua tion d’un résul tat d’inap ti tude au traite ment, et es ti mer le coû t d’hos pitali sa tion des pa tients sans traite ment dans ces cir con stances. Méth ode : À l’aide d’une base de données in for ma tique, nous avons repéré tous les pa tients de deux hôpi taux psy chia tri ques de l’On tario qui ont de mandé une évalua tion d’un résul tat d’inaptitude au traite ment sur une pé ri ode de 10 ans. Nous avons in scrit les vari ables clin iques et démo graphiques, les dates de ces sa tion et de dé but de la médi ca tion ainsi que les dates des audi e nces du con seil de révi sion et les résul tats. Nous avons égale ment tenu compte de tous les cas où un pa tient en a ap pelé en cour d’une dé ci sion du con seil de révi sion. Résul tats : Deux cent trente- sept pa tients ont pré senté 334 de mandes au con seil de révi sion. Le con seil n’a ren versé le résul tat d’inap ti tude con staté par un méde cin que dans 5 (1,5 %) demandes. Sur les pa tients, 15 ont fait ap pel de la dé ci sion du con seil de révi sion de vant les tri bunaux. Au cun de ces ap pels n’a eu de succès. En l’ab sence d’un ap pel aux tri bunaux, le dé lai moyen du dé but d e traite ment était de 25 jours. Pour les pa tients fai sant ap pel aux tri bunaux, le dé lai moyen était de 253 jours. Le coût d’hos pi tali sa tion des pa tients non trai tés pen dant la révi sion lé gale de leur ca pacité a été es timé à 3 867 000 $, dont 1 333 000 $ au raient pu être épar gnés si le traite ment avait dé buté im médi ate ment après la con fir ma tion de l’inap ti tude par le con seil de révi sion. Con clu sion : Il y a eu des dé lais pro lon gés du dé but du traite ment psy chia tri que pour quelques patients. Ces dé lais sont as so ciés à la révi sion lé gale de l’ap ti tude au traite ment. Il y a de sé rieux risques clin iques et des coûts con sidé rables as so ciés aux dé lais de traite ment des patients souf frant de mala die psy chia tri que ai guë. Lor sque les tri bunaux révis ent l’ap ti tude au traite ment, nous re commandons que le traite ment ne soit pas empêché une fois que le con seil de révi sion a con firm é une con sta ta tion clin ique d’inap ti tude.
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