The right to set out preferences for treatment in advance, nominating a person to receive information about your treatment and having the right to a second psychiatric opinion are some of the critical new rights in the Mental Health Act 2014. Bodily restraint now includes “physical” restraint as well as mechanical, and seclusion can only be authorised to prevent imminent and serious harm.
Advance statements of a person’s treatment preferences
Provisions have been introduced that provide for a person to make an advance statement setting out their preferences in relation to treatment, to be used in the event they become a compulsory, security or forensic patient
Advance statements can be an important way of documenting wishes, and a factor that must be considered by the authorised psychiatrist and others when proposing treatment or the making of orders at different times, as well as by the MHT when making orders and determining setting and duration. They must also be considered in informing a determination of whether treatment is least restrictive.
An authorised psychiatrist may override a person’s preferences in their advance statement when making a decision to administer compulsory treatment, where they are satisfied that the person’s preferred treatment is not clinically appropriate or is not a treatment ordinarily provided by the designated mental health service, in accordance with section 73. The person should be informed of the decision and the reasons for it and may request written reasons, which should be provided within 10 business days after receiving the request.
Section 20 outlines the requirements in making an advance statement, including that it must be in writing, signed and dated by the person making it and witnessed by an “authorised witness”. This can be a registered medical practitioner, a mental health practitioner, or a person who may witness the signing of a statutory declaration under section 107A of the Evidence (Miscellaneous Provisions) Act 1958 (Vic) in accordance with section 20(1)(d).
The advance statement can be made at any time and is effective from the time it is made until it is revoked. Once made, it cannot be amended (s 22), however it can be revoked in either of two ways: by making a new advance statement, or by revoking it in writing and having it witnessed in accordance with section 21(2).
It is important to ensure that members of the treating team are aware that there is an advance statement. It is recommended that it is placed on the person’s medical file so that it can be identified immediately upon a person being brought to hospital or when they are dealing with the Area Mental Health Service.
The MHA 2014 also provides for a person to appoint a “nominated person” who can receive information and will be consulted at different key points in a person’s treatment, including if any restrictive interventions and orders are made. The nominated person does not have any decision-making power, but can provide the person with information and support and assist them to exercise their rights under the MHA 2014 (s 23).
Section 24 steps out the process of making the appointment, including that it be in writing, signed by the person, the nominated person and an authorised witness who is not the nominated person. Appointment is revoked by a new nomination, a document revoking the nomination, or by the nominated person declining to act, provided they take reasonable steps to inform the person the authorised psychiatrist.
It is important that members of the treating team are aware that there is a nominated person. This information should be placed on the medical file and handed to the treating team.
For a person subject to a TTO or a TO, or a security patient or a forensic patient, the law now specifically articulates a person’s right to seek a second psychiatric opinion at any time about their treatment, and whether they meets the treatment criteria. The second opinion psychiatrist can also recommend any changes to the treatment they think is appropriate.
Although the psychiatrist providing the second opinion cannot override the treatment prescribed by the authorised psychiatrist, the MHA 2014 establishes a process for them to – in certain circumstances – assess again whether the person meets the treatment criteria (s 85) and review again the person’s treatment (s 86). If the authorised psychiatrist adopts none, or only some, of the recommended changes in the report, the person can apply to the Chief Psychiatrist for a further review (s 87). They must then review the person’s treatment, and may examine the person and access health information at the designated mental health service (s 88). The Chief Psychiatrist has the power to recommend or direct changes to the person’s treatment.
The MHA 2014 continues to authorise the use of restrictive interventions such as restraint and seclusion, but aims to improve safety and accountability in their use. Both restraint and seclusion are highly intrusive practices that can cause trauma and distress, and have been associated with serious harm and even death.
Part 6, division 1 sets out general principles for the use of restrictive interventions, including that:
•they may only be used after all reasonable and less restrictive options have been tried or considered and have been found to be unsuitable (s 105);
•that when used, a person’s needs are met and dignity protected, including provision of facilities and supplies (s 106); and
•that as soon as practicable after it is commenced, relevant people including the nominated person, are notified (s 107).
Bodily restraint now includes “physical or mechanical restraint that prevents a person having free movement of their limbs”, not including the use of furniture. Previously only mechanical restraint was regulated.
The grounds for use of bodily restraint are more limited and it can only be used if necessary to prevent imminent and serious harm to the person or someone else, or to administer treatment or medical treatment to the person (s 113). Persistent destruction of property is no longer a valid ground. The use of bodily restraint must be authorised by the authorised psychiatrist, or if they are not immediately available, a registered medical practitioner or the senior registered nurse on duty, in accordance with section 114. Section 115 provides for the use of urgent bodily restraint where necessary as a matter of urgency to prevent imminent and serious harm to the person or someone else, and where none of the authorising clinicians are immediately available. Monitoring must also take place in accordance with section 116, including clinical reviews by a doctor at least every 15 minutes and examination by an authorised psychiatrist or doctor as directed, at least every four hours. This time frame is unchanged from the MHA 1986.
Seclusion is defined as confining a person, alone, to a room or other enclosed space from which it is not within their control to leave. Under section 110, seclusion is now only authorised if it is necessary to prevent imminent and serious harm to the person or someone else. It can no longer be used to prevent a person absconding.
Like bodily restraint, seclusion must be authorised in accordance with section 111 by the authorised psychiatrist or doctor or senior registered nurse, however there is no provision for the use of urgent seclusion. Seclusion must also be monitored in accordance with section 112, including clinical observations at least every 15 minutes and examination by the authorised psychiatrist or doctor as directed at least every four hours.
A patient (compulsory, security or forensic patient) may be given medical treatment once informed consent is obtained. However, where the person does not have the capacity to given informed consent, MHA 2014 retains provisions for consent being provided by either:
•the first available person among a list of people, including (if the person is an adult) an agent under the Medical Treatment Act 1988 (Vic), a person appointed by VCAT to make the medical decision, a guardian appointment with appropriate powers, an enduring guardian with such powers, or the authorised psychiatrist;
•a health practitioner, if satisfied that the medical treatment is urgently needed to save the person’s life, prevent serious damage to their health or prevent them suffering or continuing to suffer.
Medical treatment includes any medical or surgical procedure, operation or examination normally carried out by or under supervision of a doctor, as well as dental treatment, prescription drugs (s 7). It does not include a “special procedure” (procedures related to fertility, pregnancy or tissue donation) or medical research procedure, which are covered by part 4A of the Guardianship and Administration Act 1986 (Vic).