Victoria's Mental Health Services

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Non-Psychiatric Treatment / Medical Procedure

Major Non-Psychiatric Treatment and Major Medical Procedure

• Purpose
• Background
• Definitions
• Informed Consent
• Consent Where the Person is Unable to Give Informed Consent
• Second Opinion
• Consent in Emergency Situations
• Documentation
• Other Non-Psychiatric Treatments
• Appendix 1
• Appendix 2

Purpose

To define major non-psychiatric treatment and major medical procedure, outline the requirements for consent for these treatments and examine some clinical standards issues.

Background

Under the amendments to the Mental Health Act 1986 (the Act) which were proclaimed on 1 July 1996, the Chief Psychiatrist is required to issue written guidelines which define major non-psychiatric treatment for the purposes of the Act.

Definitions

Section 83 (1) of the Act defines non-psychiatric treatment as:

• any surgical operation or procedure or series of related surgical operations or procedures;
• the administration of an anaesthetic for the purpose of medical investigation; or
• the administration of any course of treatment or course of medication requiring a prescription or medical supervision - the primary purpose of which is not the treatment of any mental disorder or the effects of mental disorder.

Within this definition, the Act focuses on two groups of non-psychiatric treatments Major-Non Psychiatric Treatment, as defined by the Chief Psychiatrist and Major Medical Procedure, as defined by the Guardianship and Administration Board.

Major Non Psychiatric Treatment is defined as:

• any surgery performed under a general or regional anaesthetic;
• the use of general or regional block anaesthetic for any purpose;
• a course of contraceptive medication commenced during involuntary admission;
• chemotherapy; and
• radiotherapy.

Major Medical Procedure is defined as:

• termination of pregnancy;
• any procedure resulting in permanent sterilisation (both female and male); and
• donation of non-regenerative tissue.

Informed Consent

Under section 53B, informed consent to a major non-psychiatric treatment or a major medical procedure requires that a person gives consent after:

• receiving a clear explanation containing sufficient information to enable him or her to make a balanced judgement;
• receiving an adequate description of benefits, discomforts and risks without exaggeration or concealment;
• being advised of any beneficial alternative treatments;
• any relevant questions asked by the person have been answered and the answers have been understood by the person; and
• a full disclosure has been made of any financial relationship between the person seeking informed consent or the registered medical practitioner who proposes to perform the treatment, or both, and the service, hospital or clinic in which it is proposed to perform the treatment.

The candidate for treatment must be given the brochure Major Non-Psychiatric Treatment and Major Medical Procedure and an oral explanation of the information in the brochure. If the person appears not to have understood, arrangements must be made to convey the information to the person in the language, mode of communication or terms which the person is most likely to understand.

The authorised psychiatrist is responsible for ensuring that the requirements for informed consent have been met.

Consent Where the Person is Unable to Give Informed Consent

Major Non-Psychiatric Treatment

Where a patient is incapable of giving informed consent to a major non-psychiatric treatment, consent may be given by the guardian (if the person has one) or the authorised psychiatrist.

If an appointed guardian is unwilling or unable to give consent to a necessary non-psychiatric treatment, an application should be made to the Guardianship and Administration Board for a review of the guardianship order.

Major Medical Procedure

The consent of an appointed guardian and the Guardianship and Administration Board is necessary where a patient is incapable of giving informed consent to a major medical procedure. If the patient does not have an appointed guardian, the authorised psychiatrist should apply to the Guardianship and Administration Board to have a guardian appointed to be involved in the decision about the treatment. (The authorised psychiatrist can not consent to the performance of a major medical procedure.)

If both the guardian and the Guardianship and Administration Board believe the person is not capable of giving informed consent and the treatment is in the person’s best interest, they may consent to the major medical procedure.

Second Opinion

Where the authorised psychiatrist is to consent to a major non-psychiatric treatment, it may be advisable to obtain a second opinion. This will apply especially where the proposed treatment is unorthodox, controversial, involves significant risk, or where the person is strongly resistant to the proposed treatment.

Consent in Emergency Situations

Informed consent is not required in an emergency where the non-psychiatric treatment is necessary to save the life of the person.

Documentation

Consent for a major non-psychiatric treatment is recorded on, Consent to Major Non-Psychiatric Treatment (PSY 19).

Consent for a major medical procedure is recorded on:

• Consent to Major Non-Psychiatric Treatment (PSY 19), if the person consents to the treatment; or
• The Guardianship & Administration Board form, Approval for Major Medical Procedure, if the person is unable to give informed consent.

A copy of the guardianship order should be placed in the clinical file.

Register of Major Non-Psychiatric Treatment

Section 85 (2) and (3) of the Act requires that the authorised psychiatrist of each approved mental health service establish and maintain a register of major non-psychiatric treatment in accordance with Schedule 3A of the Mental Health Regulations (see appendix 1). Copies of each written consent to a major non-psychiatric treatment must be attached to the register.

The Chief Psychiatrist requires that the authorised psychiatrist also enter details of all major medical procedures in the register.

General Documentation Requirements

In addition to the statutory requirements for documentation, good clinical practice requires that the clinical file show documentation of the requirements of professional standards of practice, guidelines and relevant local policy and procedures. These requirements include:

• A patient management plan.
• The rationale for the proposed non- psychiatric treatment.
• Details of the process of gaining consent.
• Details of any second opinions where applicable.
• Where the guardian has given consent to the non-psychiatric treatment, a copy of the guardianship order should be in the clinical file.
• The response to treatment.

Other Non-Psychiatric Treatments

There are a whole range of procedures and investigations which are not classified as major non-psychiatric treatments or major medical procedures, but which still fall within the definition of non-psychiatric treatments.

Under section 83(2), informed consent to other non-psychiatric treatments that are not considered a major non-psychiatric treatment or a major medical procedure, requires that a person gives free and voluntary consent in writing after receiving:

• a clear explanation of the proposed non-psychiatric treatment; and
• advice as to the reason why the non-psychiatric treatment is necessary.

If the person is incapable of giving informed consent to the treatment, consent may be given by the guardian (if the person has one) or the authorised psychiatrist.

Consent for non-psychiatric treatment is recorded on Consent to Non-Psychiatric Treatment (PSY 18). Other documentation should be consistent with local practice. There is no requirement to keep a register of these treatments.

DR CARLYLE PERERA
Chief Psychiatrist

NON-PSYCHIATRIC TREATMENT-CLINICAL AUDIT

Standard 1: Each area mental health service shall have an established policy and procedure concerning non-psychiatric treatment.

Indicators:

1.1 There is a written policy and procedure concerning non-psychiatric treatment based on, or advised by, the guidelines issued by the Chief Psychiatrist.

1.2 Clinical staff are able to articulate a working knowledge of the key principles, statutory requirements and issues about the classes of non-psychiatric treatment and relevant local policy and procedures.

Standard 2: That where a person who is in receipt of treatment for a mental disorder has a non-psychiatric treatment, that the clinical file demonstrates sound clinical practice and that the requirements of these guidelines have been met.

Indicators:

2.1 Clinical file documentation contains the requirements of these guidelines and local policy and procedures.

2.2 Each person has a documented management plan that includes identification of the non-psychiatric condition, related clinical needs and strategies for their management.

2.3 The rationale for the decision to provide the major non-psychiatric treatment or major medical procedure is contained in the clinical file.

2.4 Details of the process of obtaining informed consent are recorded and a copy of the consent form is in the clinical file.

2.5 Details of second opinions, where applicable, are recorded.

2.6 Where the appointed guardian gives consent to the non-psychiatric treatment, that a copy of the guardianship order is in the clinical file.

2.7 Where the procedure is a major medical procedure, a copy of the Guardianship and Administration Board Act form Approval for Major Medical Procedure is in the clinical file.

Appendix 2

SCHEDULE 3 A

Regulation 7

Mental Health Act 1986 (Section 85)

Mental Health Regulations 1987

REGISTER OF MAJOR NON-PSYCHIATRIC TREATMENT

for ...........................................................................................................
approved mental health service

Major non psychiatric treatment was performed on the following patients during the month of ............................................... 19 .................

Copies of written consents to major non-psychiatric treatment are attached for all patients listed above.

................................................................................................................
GIVEN NAME(S) FAMILY NAME (BLOCK LETTERS) of *delegated/authorised psychiatrist

Signed ........................................................ date ..................................

*circle as necessary