Treatment plans

Definitions

Advance care directive: A document that sets out a person's values and/or preferences in relation to treatment in the event that the person lacks capacity to make treatment decisions and is not a patient under the Mental Health Act 2014 ('the Act').

Advance statement: A document that sets out a person's preferences in relation to treatment in the event that the person becomes a patient under the Act.

Authorised psychiatrist: A person appointed as an authorised psychiatrist for a designated mental health service under s. 150 of the Act.

Care: The provision of ongoing support, assistance or personal care to another person.

Carer: A person, including a person under the age of 18 years, who provides care to another person with whom they are in a care relationship but not including a parent if the person to whom care is provided is under the age of 16 years.

Consumer: Any person receiving mental health services from a mental health service provider, regardless of their legal status.

Medical treatment: Any treatment with physical or surgical therapy including treatment for mental illness, treatment with prescription pharmaceuticals, dental treatment and palliative care. Treatments for mental illness include interventions requiring professional skills to remedy the mental illness or to alleviate the symptoms and reduce the ill effects of the mental illness. Treatment includes electroconvulsive treatment and neurosurgery for mental illness.

Medical treatment decision-maker: A person who meets criteria in the Medical Treatment Planning and Decisions Act 2016 to make treatment decisions for another person who lacks capacity to make treatment decisions and is not a patient under the Act.

Nominated person: A person appointed to: provide a patient with support; represent the interests of the patient; receive information about the patient in accordance with the Act; be one of the persons who must be consulted about the patient's treatment, and assist the patient to exercise any rights they have under the Act.

Patient: A person who is subject to an assessment order, temporary treatment order or treatment order under the Act.

Support person: A person appointed under the Medical Treatment Planning and Decisions Act 2016 to support a person who is not a patient under the Act to make, communicate and give effect to the person's medical treatment decisions and to represent the interests of the person in respect to medical treatment, including when the person does not have decision-making capacity. The support person does not have the power to make the person's medical treatment decisions.

Purpose and scope

This new guideline has been developed in response to a recommendation made in the Chief Psychiatrist's Audit of inpatient deaths 2011-14 to set a minimum standard for treatment planning in mental health services. The guideline covers all programs (child and adolescent, youth, adult, aged and forensic) and all settings (inpatient, community, residential and speciality services).

Mental health services are expected to develop their own policy and procedure documents that adhere to, and expand on, this guideline.

Mental Health Act principles

When participating in treatment planning, service providers must have regard to the mental health principles, as expressed in the Mental Health Act 2014. These include that all persons receiving mental health services should be provided assessment and treatment in the least restrictive way possible and be involved in, and supported to make, all decisions about their assessment, treatment and recovery.

Recovery refers to a unique personal experience, process or journey that is defined and led by each person with a mental illness. It is owned by, and unique to, that person. The role of mental health services is to create an environment that supports, and does not impede, recovery efforts.

Treatment plan principles

Treatment planning should:

• be led by consumers and respond to their identified recovery goals and preferences
• be recovery-oriented and strengths-focused
• include all people involved in the consumer's mental health care, including the treating team, carers, guardians, support persons and nominated persons
• be documented on a specific template
• be written in language that is easy to understand, with a copy provided to the consumer.

Preparing to write a plan

Timing

Treatment planning starts as soon as possible after a consumer enters a mental health service. It begins with an understanding of the person's recovery goals and preferences and evolves as a collaborative process in keeping with the principles of supported decision-making.

In acute inpatient units, a draft plan should be prepared wherever possible within one working day of admission. A more complete version should be completed by the time of discharge from the ward. In community teams, a plan should be completed within one month.

Supported decision making

Information should be provided to consumers in a way that they understand to ensure they can adequately weigh up the risks and benefits of treatment and consider treatment options. Using advance statements (or advance care directives for people not under the Act) and involving support persons, nominated persons, independent advocates and providers of second psychiatric opinions will enhance participation.

If consumers have difficulty expressing their views and preferences, or contributing to decisions about treatment, then actions must be taken to ensure the principles of supported decision making are upheld. These include finding ways to improve and develop decision-making capacity by means of discussions, meetings and education.

There may be times where consumers do not want to participate in treatment planning. This needs to be clearly documented in the clinical file and any treatment planning documentation. Consumer involvement in treatment planning should be regularly reviewed and promoted and the advance statements, nominated person and carers should be accessed if available.

If a consumer who is not a patient under the Act does not have decision-making capacity, their advance care directive must be considered, if one exists, as well as the views expressed by their medical treatment decision-maker and support person as described in the Medical Treatment Planning and Decisions Act 2016.

If a patient does not have decision-making capacity, their advance statement must be considered, if one exists, as well as the views and preferences of their nominated person and carer (if treatment affects the care relationship) as outlined in the Mental Health Act.

Consent to treatment

The treatment plan will be shaped by issues of consent to treatment, bearing in mind the need for consumers to be supported to make their own informed decisions wherever possible.

The authorised psychiatrist is responsible under the Act for the treatment and care each consumer receives. Before treatment is administered to a person, their informed consent must be sought. When seeking informed consent to a treatment, the authorised psychiatrist must presume that the person has the capacity to give informed consent to treatment, regardless of their legal status, unless lack of capacity can be demonstrated by means of a detailed clinical review.

A person has capacity to give informed consent to treatment if they:

• understand the information they are given that is relevant to the decision
• remember this information
• use or weight the information
• communicate the decision they make by means of speech, gestures or any other means.

However, if the person is a patient, the authorised psychiatrist may make a treatment decision for the patient if they are satisfied there is no less restrictive way to provide treatment.

Assessment orders

Treatment while an assessment order is in place should only be provided if:

• the person gives informed consent to the treatment, or
• a registered medical practitioner is satisfied that urgent treatment is necessary to prevent serious deterioration in the mental or physical health of the person or serious harm to the person or to another person.

Nominated persons, guardians and carers

Carers can play an important role in supporting people with mental illness, but their role is often made difficult by the wide-ranging consequences of the mental illness. The Act requires that the authorised psychiatrist have regard to the views and preferences regarding treatment of guardians, carers and nominated persons who are involved in providing patients with ongoing care or support. Carers will often have views and preferences that they wish the treating team to take into account when developing a treatment plan. The role of families and carers in the treating relationship should therefore be raised with the consumer as early as possible.

The extent to which carers have their wishes taken into account will depend on the consumer. Where carers, including dependent children, are to be involved in the treatment planning process, the treating team should consult with them on a regular basis. In addition, the treating team should ensure that an assessment is made of the needs of carers and dependent children, both to support the recovery of the consumer and to maintain their own health and wellbeing. These needs should be incorporated into the plan and updated at critical points.

The consumer's clinical record should identify any nominated person, carers, support persons and nominated persons for the purposes of consultation and their involvement in discussions. Decisions should then be documented.

If the consumer refuses involvement by carers, the subject of available ongoing supports should be periodically revisited to ensure all supports are identified.

If a consumer refuses a carer's involvement, or permits only limited involvement, carers will still benefit from information about mental illness, guidance about responses to concerns or crises, and pointers to accessing assistance and support for themselves.

Information sharing

Developing a comprehensive treatment plan may benefit from sharing information with other healthcare providers (general practitioners, psychologists and private psychiatrists) and carers, guardians, support persons and nominated persons, where they exist.

The circumstances under which a patient's health information can be disclosed to other parties include situations where:

• the person to whom the information relates consents to its disclosure
• this disclosure is reasonably required by a carer of the patient to determine the nature and scope of the care to be provided to the patient and to make the necessary arrangements in preparation for that role and to provide care to the patient, having regard to the patient's views and preferences, including those expressed in any advance statement
• this disclosure is required by another mental health service provider, or health service provider, to provide health services to the patient.

Enlisting consumer supports

Consumers should be encouraged to include support persons and nominated persons in these discussions. They should be told of the Independent Mental Health Advocacy service, and an independent advocate should be involved in discussions if the consumer requests it.

These discussions should address the benefits and risks of recommended treatments, alternative treatments and no treatment in a collaborative, supportive spirit to promote informed decision making.

Treatment plan meetings

Treatment planning can take place in a variety of circumstances and settings (for example, a clinical review or family meeting) provided consumers are present and have given their consent to the presence of a carer, guardian, support person, nominated person, independent mental health advocate or interpreter.

Consumers must be given time and support to:

• express their goals, values and preferences regarding treatment
• disagree with treatment if they wish
• contribute to treatment decisions as much as possible.

The purpose and format of the meeting should be explained and a record kept of the discussion. This record can become the treatment plan.

Relevant and available treatment options, including psychological therapies, must be presented, with consideration of benefits, risks, alternatives, costs, expected outcomes and review timeframes.

Attention should be paid to consumers' mental health, medical, physical and social needs. Risk factors to be weighed include worsening of mental health symptoms, suicidality, use of alcohol and other drugs, accommodation, family (including the needs of any dependent children), domestic violence, finances and employment.

Restrictive treatments can also pose a risk to the relationship between the consumer and the treating team and should be factored into discussions.

For people who lack capacity to give informed consent to treatment, or who are subject to treatment on a compulsory basis, discussions should articulate the steps to be taken to support the person to contribute to decision making, regain capacity and be discharged from treatment under the Act.

Writing a plan

Individual and cultural needs

When writing a treatment plan, the consumer's individual needs and preferences are paramount. Cultural considerations must be considered, including perspectives on mental health, mental illness, medical comorbidities, religious practices, gender and sexuality. If required, interpreters must be invited to planning meetings.

Content of plans

Treatment plans should:

• prioritise the consumer's recovery goals and immediate needs, with a focus on self-determination, strengths and aspirations
• identify potential risks, including plans to mitigate them
• list treatment strategies and objectives, and alternatives that have been considered
• state what the service will do to address identified needs, who is responsible for each action, timeframes and expected outcomes
• summarise the consumer's opinion of the treatment plan
• include steps to meet carers' needs (where applicable).

Documentation

While services are free to record treatment planning discussions in a variety of formats, a template is provided for convenience (see appendix). This document can be used in conjunction with more detailed, longer term plans including individual service plans and recovery plans.

Treatment plans must be legible, easy to understand, unambiguous and free of abbreviations and jargon. They must be stored in a way that allows quick, easy access.

There is space for consumers, nominated persons and carers to sign the plan if they wish, indicating their agreement with its contents.

A copy of the plan should be provided to consumers and, where appropriate, to guardians, carers, support persons and nominated persons.

For patients, a current treatment plan that follows the format shown in the appendix is acceptable to the Mental Health Tribunal for use in its hearings.

Inpatient settings

The treatment plan for an acute inpatient should address consumers' immediate needs including the needs identified by the person and any identified risk factors. Given the dynamic nature of treatment and care in an inpatient setting, the plan need not specify elements that are subject to rapid change but should focus instead on treatment objectives and include information that consumers need to help them understand their treatment and participate in treatment decisions.

Subsequent plans should include more detail and specify the discharge plan and follow-up care.

Implementation

Where reasonably practicable, the authorised psychiatrist should personally discuss the plan with the consumer, but this can be delegated if required to the case manager, treating doctor or another appropriate member of the treating team. An interpreter must be used if required.

All members of the treating team, and in particular the key clinician, should regularly discuss treatment issues and available services with the consumer. The treatment plan is meant to augment, not substitute for, other discussions with consumers regarding their treatment.

Throughout treatment, the treating team should continue to encourage and support consumers to develop an advance statement to capture their preferred treatment options in the event that they require compulsory treatment and they do not have capacity to make treatment decisions. An advance care directive captures preferred treatment options for treatment on a voluntary basis.

If patients are dissatisfied with their treatment plan, they must be told of their right to an independent mental health advocate and a second psychiatric opinion and be given assistance to access these supports.

Review

Treatment planning is an ongoing process. Services should have their own policies and procedures in place that stipulate the requirements for updating documentation. For consumers in inpatient units, the treatment plan should be reviewed as requested by the person or as clinically indicated. Updated documentation should be provided to the person at least weekly.

For consumers in residential services or the community, treatment plans should be reviewed when circumstances change or as requested. At a minimum, documentation should be reviewed with the consumer and any other people identified by the consumer including the nominated person, family/carers or an advocate and updated at least every 91 days. Plans can be updated concurrently with other reviews if appropriate.

The process should be as fluid and interactive as possible and committed to writing. Copies of the revised plan should be given to the consumer (and support person, nominated person, guardian and carer as appropriate).

Indicators for quality audits

The following indicators are suitable to use in audits of compliance with this guideline:

• a local treatment plan policy and procedures document for clinicians
• a timeline for reviewing the policy and procedures document
• the proportion of consumer files that include:
  • evidence of consumer involvement
  • evidence of consumer self-direction
  • evidence of supported decision making
  • evidence of family and carer involvement, where appropriate
  • evidence that the consumer was provided with a copy of the plan
  • evidence for community consumers that the plan was reviewed within 91 days.

Appendix: Mental health treatment plan

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