"Beuty is truth, truth beuty" Keats. To my mentor and my truth is here
transparency
Here is an article psiquiatrialegal.com now particularly interested me because I work in a hospital setting. Concepts such as autonomy, information, transparency, informed consent, makes more complex the life of the inpatient units, but may help us to advance us to give a more humanized and effective services. Clinical experience tells me that a more opaque, is traumatic and forced entry by delirium, more resistant makes that person to renounce it, with as many subsequent readmissions. Greetings!
INFORMED CONSENT AND PSYCHIATRY
Western medical tradition has been built on the precept, erroneously attributed to Hippocrates, the Primum non nocere. Throughout history, this provision resulted in the physician's obligation to the patient the most good. As aptly said Diego Gracia (1) in this way were similar two distinct obligations: first, do no harm (the equivalent to the current principle of nonmaleficence), which in medicine is related to the technical skill of the physician and the other hand, seek the Good, which has a moral dimension. This action of the doctor in which pooled the technical and moral purposes was the patient, which was conceived as being affected physically, psychologically and morally for their disease and, therefore, unable to find what suited him. Until recently, it has been the transcript of the doctor - patient (or to put it more generally, health - sick). The doctor decided what was good, which suited the patient and, ultimately, what should be done, and did not count for anything in his decision with the view of the patient. In terms of modern bioethics, this historical situation encompassed the principles of nonmaleficence and beneficence. It was the doctor who competed avoid evil and do (and determine what was) the right, even against the advice of the patient. This was ultimately the basis of known historical and ethical medical paternalism.
In recent decades the relationship has entered a new health principle, that of autonomy. This principle, albeit with roots in the Enlightenment and the beginning of the modern age and has a clear relevance in other walks of life (political, social, financial) much earlier, failed to gain a place in the universe health to the recognition of the right to informed consent in American courts from the mid-50's last century. Only since then has begun to see that the patient has an important role in the relationship health and ability to make decisions regarding the care of their health problems.
Thus, the patient ceases to be incapable and immature because of his illness and becomes actively involved in their care, expressing their interests and preferences in this regard, a process in which clinicians provide information and patient consent performing diagnostic and therapeutic procedures (2). Finally recognizes the patient's ability to govern despite the disease. In our law, Law 14/86 of 25 April, General Health, breaks down the right to CI in articles 10.5 (on the right to Information), 10.6 (on the Right to Consent) and 10.9 (on the right not to consent). Article 10.6 also provides for exceptions CI: risk to public health, emergency and incapacity for decision making, in which case the right of consent shall be for the family or significant others.
Development of Informed Consent in Spain has been (is being) expensive. However, in other countries with greater autonomy tradition (3) also exist around the myths, prejudices and misunderstandings that abound in our country. Among them prominently the identification of "consent" to the important fact of signing the authorization for the practice of a diagnostic or therapeutic procedure, forgetting that informed consent is actually an ongoing process of information by the doctor (4).
ELEMENTS OF INFORMED CONSENT
Over the years it has created a body of doctrine and clinical experience about informed consent that has allowed characterization of its components: Voluntariness, information in sufficient quantity and quality, competence and validity and authenticity. All these elements are present in clinical practice and are not more or less philosophical entelechies outside the daily work.
a) Voluntariness. Except in the case of psychiatry hospital or legal imperative is not common in clinical practice the use of diagnostic or therapeutic procedures against the will of the patient. However, there are more subtle mechanisms that can affect the voluntariness of a decision, such as persuasion, coercion and manipulation.
b) Information in sufficient quantity and quality. One of the main reasons for dissatisfaction and complaint from users of health services is the lack of information. This complaint persists even when the overall outcome of health care interventions is entirely satisfactory. However, problems arise when determining the form and content of information. Clinicians remain concerned about the detrimental effects for the patient to have accurate information about their illness, and often therapeutic privilege is invoked, an updated formulation of traditional paternalistic principles holds that in certain patients and certain situations the physician should withhold or delay information. Today, however, no doubt about the patient's right to information. Thus, in principle would be important to an accurate determination of what, how and when to report. In this regard have proved illuminating successive documents and guides that we reviewed in another article.
c) Competition. Competition within the framework of informed consent refers to the fact that the patient is able to consent. It is probably the most contentious area in Psychiatry and will be dealt with more detail in another chapter.
INFORMED CONSENT IN PSYCHIATRY
Informed Consent is one element of what some authors have called the stage of mental illness as a human animal (5). Overcoming the times in which the patient was conceived in the manner of a wild animal (more imprisonment in prison mental hospitals to hospital) or a pet (with the establishment of psychiatry as a discipline to soothe and de-shake the sick) in the final third of the twentieth century has highlighted the particular need to promote the rights of patients psychiatry. And among those rights prominently informed consent.
However, implantation, and even acceptance of this right runs into obstacles and prejudices. Can you seriously consider the possibility exists psychiatric activity of informed consent? Is there the possibility of mental illness to receive information? Can there really an absence of coercion in the relationship of the patient to his psychiatrist, 'Is the patient competent?
1 .-
Mental Illness To begin to answer these questions we must say that we know too well as psychiatric practice is too broad and varied as to make generalizations. The definition of mental illness (MS) is problematic. In recent years, psychiatric classifications are preferred term, broader and diffuse Mental Disorder (TM), the DSM-IV American Psychiatric Association (6) defined as a syndrome or a behavioral pattern or psychological significance clinic, which is associated to discomfort (eg., pain), disability (eg., impairment in one or more areas of functioning) or a significantly increased risk of dying or suffering pain, disability or loss of freedom.
The scope of this vague concept is widening. Successive editions of DSM disorders are incorporating new, sometimes, are mere subdivisions of disorders identified since ancient times (for example, the multiple combinations of symptomatic and evolution of bipolar disorder), other times they are "new" disorders broken off from a common trunk encompassed less accurate than previously (for example, Asperger disorder related to autism in its various meanings and under different names it has been receiving). For Finally, do not forget that the change in the concept of abstinence and dependence has led to make room for new substance use disorders. Either way, the truth is that we are witnessing an explosion nosological staggering proportions: The DSM-II, 1968, 180 distinguished mental disorders in the third edition, revised (DSM-III-R, 1987), went to be 292, to ascend in the DSM-IV in 1994 to over 350. Face to successive editions and although the DSM consistency requires its disorders suggests a restrictive tendency, we anticipate the addition of minor depression, anxiety disorder - depression and the very variegated forms of slippage impulsive and repetitive behaviors or addictive.
With such variety of diseases is unacceptable automatically conclude that mental illness does not viable informed consent in psychiatry.
2 .- Mental Illness and Information
Although it is difficult to determine the form and content of information there is no doubt about the patient's right to it. Thus, in principle would be important to an accurate determination of what, how and when to report. Moreover, the formal aspect of the information can be a major stumbling block. Health relationship is a process fraught with uncertainty, whose recognition by the doctor can sometimes disturb the patient, accustomed to solving and operational picture of the doctor. On the other hand, even in situations of a reasonable certainty, psychiatrists have big problems to convey an intelligible our results and it is incontestable that on many occasions we fail to make us understand by colleagues from other specialties or by peers from other theoretical orientations. This represents a major challenge, as it urges us to improve our methods and channels of communication with patients In addition to forcing a minimum consensus on diagnostic and therapeutic measures all the time indicated.
The presentation of information in sufficient quantity and quality is a particularly difficult challenge when the recipient suffers from severe mental illness. The fear of a worse treatment adherence when exposed openly side effects of drugs can lead to paternalistic attitudes and excessive use of therapeutic privilege. However, there is no evidence to support this fear (7).
As in any another situation, the information must include the risks and benefits of treatment, and alternatives. It is an ongoing process that requires the psychiatrist to clarify the doubts each time the patient. It is proposed that information on antipsychotics should include a comprehensive list of side effects, with an explicit reference to the most serious, but statistically infrequent (8).
worth collecting to talk about some practical information on psychotropic drugs spurious negative publicity are reporting side effects of new antipsychotic drugs those who are not accustomed. In addition to discredit Psychopharmacology may pose to the wolf would be unfortunate if the marketing is camouflaged under the skin of the lamb of the rights of patients.
3 .- Mental Illness and Will
If, as Henri Ey said mental illness is the pathology of Liberty, the voluntariness of the decisions of psychiatric patients may be questioned. But aside from the actual intrapsychic factors derived from the disease, the patient is exposed to a particular risk of improper inducements, coercion or manipulation. The psychiatrist holds an authority issued even to some extent on political or administrative bodies, which can convert the relationship with the patient in a particularly unequal struggle. In other cases, therapeutic measures arise in a coercive manner. In the case of placements, provided plans to the threat of entry clearance unless the patient agrees to enter. However, behind these pressures on the patient's will is not the disease, but how to make professional or institution.
4 .- Mental Illness and
Competition Competition required to consent varies according to the decision or clinical situation in question, so although there are many cases in which the psychiatric patient is not competent, they are certainly not the majority. This aspect will be addressed in another chapter.
PSYCHIATRIC INFORMED CONSENT AND INCOME: Income "INVOLUNTARY"
The power to impose a subject a psychiatric hospitalization for reasons related to the two basic powers that Aristotle gives the State (9). On the one hand, police power, which protects citizens danger and injury and, moreover, the Parens Patriae to help people in need of parental support (maintenance, protection, food and education), assuming the role as father of all citizens who have no family or relatives who to succor in times of need. The power of protection from danger and harm is the basis for the forced internment of the danger arising from the subject, while the paternalistic role of the state justifies its intervention to enter and treat people who need help to regain health or prevent further deterioration of the same.
Throughout history, psychiatric institutions have been met in relation to the mentally ill this dual role. On the one hand have served to protect the Company from allegedly dangerous mentally ill (or annoying, or lewd and uncomfortable to see.) On the other hand have had a paternalistic order or impose aimed at helping the patient support.
The judicial control of detention is relatively old, emerged in France with the Act of 1838, which remained in effect until 1990 and established safeguards to prevent arbitrary income and protect the individual rights and property of the patient. This Act had a profound effect across Europe and appearing under his influence were various national laws. The first English law is to be found in the Royal Decree of 19 May 1885 on Civil Confinement of the Insane, prior to the appearance of the first Civil Code (1889). Such initial distinction between observation income, administrative, for a period of six months, later extended to one year imprisonment and ultimately to judicial control. The family played a key role, could apply for admission for observation and automatically cancel the detention even though the patient was dangerous, always take charge of his custody and took the resulting responsibilities. It was therefore of income in which ownership rested with the family and whose purpose was to fend off social life to people who could not lead a normal life.
legislation was replaced by the Decree of July 3, 1931 on Assistance for Mentally Ill, which in Article 10 distinguishes between the terms for entering the "admission of a mental patient for medical reasons (involuntary admission) [that] only may have the character of the treatment medium and in any correctional deprivation of liberty. " The new rules, raised with therapeutic zeal, the main protagonist was, therefore, the doctor who was who suggested the measure.
From the 60's throughout the Western world took place several changes designed to better legal protection of the mentally ill, particularly those subject to involuntary. As part of this movement, in 1983, Spain was in an amendment to the Civil Code, which repealed the Decree of 1931 and stemmed from the changes described internationally as well as the need to harmonize their admittance to the still new Constitution of 1978 and the European Convention Human Rights, ratified by our country in 1979. The new legislation was laid on judicial authority to protect the rights of the patient. The new Article 211 of the Civil Code provided that:
The detention of a suspected unable to require prior judicial authorization, except in emergencies would warrant the adoption of such a measure, which will realize as soon as the judge and, any event, within twenty-four hours.
The judge, after examining the person and heard the advice of a physician designated by him, grant or refuse permission and make the facts known to the Ministry Attorney for the purposes stated in Article 203.
Among other features, the new regulation had the defect, or perhaps the virtue of linking the forced internment in a situation of incapacity or incompetence of the subject, rather than its rejection of the measure. In terms of informed consent, and although related to involuntary admissions, the law did not speak of will but of competence.
Later, during Act 1 / 1996 of January 15 on the Legal Protection of Minors, a change was introduced In the drafting of Civil Code No. 211:
Internment by reason of mental disorder, a person who is not able to decide for itself, but is subject to parental authority, require judicial authorization (...).
The new version, even more explicitly in the paternalistic rationale of the measure, remains essentially in Article 763 of the new Civil Procedure Act. In short, it would not be appropriate to speak of involuntary admission, but incompetent income. The qualification is important in light of the White Paper Committee Ministers of the Council of Europe on the protection of human rights and dignity of persons with mental illness, especially of those found in psychiatric institutions, that the criteria for involuntary admission appointment:
c. The person is able to consent and refuses consent to the entry (the person is capable of consenting but explicitly rejected or not acted upon) or the person is unable to consent and refuses admission or treatment.
In terms of the elements of CI, according to this document, the involuntary admission would be a question of involuntariness and / or incompetence, against English law, which only mentions the incompetence, that the incompetent person is not openly opposed to income should not be considered voluntary, but that their income would require court approval.
The shift of the competition will have its implications. First, being a purely paternalistic or protective, the question is obvious, perhaps uncomfortable, indications, among which we should mention the protection of third parties. In this way, it avoids a certain institutionalization or prosecution of the role of control Social Psychiatry. At the same time, the English psychiatric care may dismiss the civil revenue forced a group of patients in other countries would be subsidiaries of this measure. This is the case of people with antisocial personality disorder to reject the entry, who can be considered qualified to do so, provided that they present a comorbid disorder that may affect their competence. Thus, the absence of an "indication of danger" of psychiatric admission (as can be, for example the English Mental Health Act) can throw their forced internment.
Moreover, the absence of more explicit rules on involuntary or forced treatment, the fact that the patient has received an initial assessment of disability, at least to decide on their income, would allow the imposition of other therapeutic measures. Do not forget, in this sense that one of the exceptions to consent, according to Article 10.6 of the General Health Law, is the disability.
Finally, it is questionable falsely able income, or if you prefer, erroneously considered competent. This situation gave rise in the U.S. in a court case (Zinermon v, Burch), in which the litigant sued a hospital that accepted him as a voluntary patient in a state of psychotic decompensation franca that made his signature on the application form for admission or consent is invalid. Beyond the specifics of the case, the trial court decision favorable to the APA forced the competition to formulate criteria for voluntary hospitalization.
any case, Article 763 of the new Civil Procedure Law, Article 763, which has replaced 211 of the Civil Code refers to "involuntary detention because mental disorder "despite raising the issue in terms of competence or incompetence will not:
1. Internment, by reason of mental disorder, a person who is not able to decide for itself, but is subject to parental authority or guardianship, will require court approval, to be collected from the court where the person lives affected by internment.
The institution of voluntary membership data in psychiatric centers in our country of the Decree of 1931 and is spread throughout the world. In 1993 Group of the APA Task Force on Consent to Voluntary Hospitalization described the virtues of this procedure (10):
a. Defends patient autonomy by allowing the decision to enter
b. Maximizes the patient's rights, including those treated in the least restrictive framework and apply for discharge. C.
Reduce the stigma associated with hospitalization
d. Expand access to hospital treatment, as not all patients who could benefit from hospitalization voluntary fulfillment of stringent conditions for involuntary admission
e. Lets start treatment before there is a significant deterioration in the clinical situation
f. Creates the framework for establishing a cooperative relationship with increasing patient responsibility and enhance their participation in treatment.
g. You may have a more favorable outcome than involuntary hospitalization
h. Avoids the enormous costs involved for health and justice systems to be handled as involuntary patients admitted many volunteers.
addition, the Task Force notes, the guarantees that have voluntarily hospitalized patients are clinical and not legal.
With a few nuances arising from different health care and legal frameworks, these arguments are perfectly applicable to other countries. What does not seem so lucky to describe these income and participation in voluntary income. In light of the theory of informed consent, from the wording of our laws and even the peculiarities of the American context, it is more appropriate to speak of income consented to voluntary income. The Task Force itself was established to determine the conditions of consent of income and what characterizes what is commonly defined as voluntary income is the patient's consent to enter, on the basis of adequate information, not their will violentación and a sufficient degree of competition. Likewise, in this sense, the term more appropriate to define what is usually called involuntary admission income would not consented or forced entry. Bibliography
1 .- Grace D. Primum non nocere. Madrid: Institute of Spain - Royal Academy of Medicine, 1990
2 .- Simon P. Informed consent. Madrid: Triacastela, 2000
3 .- Meisel A, Kuczewski M. Legal and Ethical myths about informed consent. Arch Intern Med 1996; 156: 2521-6
4 .- Lidz CW, Appelbaum PS, Meisel A. Two models for the application of informed consent. In: Couceiro A (Ed). Bioethics for clinicians. Madrid: Triacastela, 1999, pp 151-162
5 .- Gracia D, Lazarus J. History of Psychiatry. In: JL Ayuso Gutiérrez, Salvador Carulla L. Manual of Psychiatry. Madrid: Interamericana - McGraw - Hill, 1992, pp 17 to 31
6 .- American Psychiatric Association. DSM-IV. Diagnostic and Statistical Manual of Mental Disorders, 4th edition. Barcelona: Masson
7 .- Lidz CW, Hoge SK, Gardner W, Bennett NS, Monahan J, Mulvey EP, Roth LH. Perceived coercion in mental hospital admission. Arch Gen Psychiatry 1995, 52: 1034-1039
8 .- Jeffries JJ. Ethical Issues in drug selection for schizophrenia. Can J Psychiatry 1993; 38 (suppl 3): S70-S74
9 .- LaFond JQ. Law and the delivery of involuntary mental health services. Am J Orthopsychiatry 1994, 64: 209-222 10 .- Cournos
F, Faulkner LR, Fitzgerald L, Griffith E, Munetz MR, Winick B. Report of the Task Force on Consent to Voluntary hospitalization. Bull Am Acad Psychiatry Law 1993; 21: 293-307
