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Chief Psychiatrist's Guidelines Index < General medical health needs, annual examination, non-psychiatirc treatment, special procedures and medical research procedures - January 2008
Public mental health services have a responsibility to assess and, where required, manage the physical and medical health needs of people receiving treatment from their service. To provide information about the law and clinical policy requirements concerning:
People with mental illness are at higher risk of a range of physical problems and illnesses and may be prescribed medications with significant potential for interactions and side effects. Risk factors in this population may include smoking, alcohol and substance use, obesity, poor diet and other lifestyle factors. Additionally, some people may have an itinerant lifestyle, be at increased risk of self-neglect or may misattribute or have difficulty describing physical symptoms. As a result, they are often less likely than the general population to access appropriate healthcare. As opportunities for liaison between mental health services, general medical services, and primary care physicians have increased, in many instances people will be referred to other medical practitioners for examination, investigation, and ongoing management of physical conditions. Providing integrated care can be a challenge when multiple service providers are involved and it is possible an individual’s physical health needs may be overlooked. It should not be assumed that a person receives regular physical health checks just because there is a primary care physician identified in the person’s clinical record. People receiving treatment from public mental health services, whether on a voluntary or involuntary basis, are entitled to access quality care for their mental and physical health needs. Where a person is unable to readily access physical health care due to mental health reasons, the mental health service should facilitate or provide such care. The authorised psychiatrist maintains a responsibility for the physical as well as the mental health of patients (involuntary, security and forensic) under the Mental Health Act 1986, including those people on community treatment orders and restricted community treatment orders. Identifying medical conditions Medical conditions may imitate, exacerbate or mask psychiatric symptoms and some treatments for mental illnesses may have significant physical side effects in both the short and long term. Diagnosis and appropriate care of physical illness is therefore essential to prevent deterioration in a person’s health and to optimise management of their mental illness. Accordingly, mental health services should ensure people have a comprehensive medical assessment in order to address physical conditions, in particular those that may be impacting on their mental state. Medical history A medical history is an essential part of psychiatric assessment. The history should summarise the person’s current state of health and identify past medical or surgical treatment, current and recent prescribed medications and their indications, and any use of non-prescribed substances. The medical practitioner taking the history may refer to previous histories in the person’s clinical record, but should confirm the accuracy of key information with the person. Physical examination The physical examination is an important diagnostic tool. Medical practitioners need to clearly explain the reason for a physical examination and what it will involve. It is also essential to gain a person’s consent or substitute consent before proceeding with the examination (see ‘Consent to physical examination or medical treatment’). Consideration should be given to having another health professional of the same gender as the person present for an examination. Attention should be given to a person’s cultural and other needs. In the case of a child or adolescent, a parent, guardian or a health professional of the same gender as the young person should be present during a physical examination. When a person is admitted to a psychiatric inpatient unit, a physical examination should be performed and documented as soon as possible. Where initial physical examination is limited by the mental state of the person, a more complete examination should be performed and documented at the earliest possible opportunity. Appropriate investigations should be ordered and results noted and acted on as required. In the community, the requirement for a physical examination will depend on the clinical needs of the person and their individual circumstances. If a person has a general practitioner, it would be sufficient for the mental health service to encourage the person to have regular health checks and to liaise with the practitioner about the person’s physical health and their needs. If a person does not regularly access other primary health care services, a medical practitioner from the mental health service should physically examine the person periodically. Emergency departments People presenting to an emergency department will usually have a general medical evaluation to enable adequate diagnostic assessment or treatment decisions to be made. While this information can contribute to the psychiatric assessment of the person, psychiatric assessments should not be routinely delayed while awaiting medical evaluation. Issues for aged psychiatry services The older population has an increased incidence of medical comorbidity including medication interactions and toxicity. It is important to consider delirium in new presentations and in relapse of established illness, and to communicate closely with community practitioners. The possibility of elder abuse is also to be considered in situations of trauma. Aged persons mental health residential services The authorised psychiatrist has a responsibility for ensuring the physical and medical needs of people in aged persons mental health residential services (APMHRS) are met. While the examination, investigation and ongoing management of physical conditions may be performed by geriatricians, medical practitioners employed by the APMHRS and general practitioners, the authorised psychiatrist has a responsibility to ensure that residents in APMHRS receive adequate and appropriate psychiatric and physical care. The Commonwealth’s residential outcome standards specify that all residents are entitled to a general practitioner of their choice. While most residents will have a listed general practitioner, it cannot be assumed that a person’s medical needs are always being actively managed. Further, the possibility of interactions between medications prescribed for physical and psychiatric conditions and the potential for side effects and toxicity associated with psychiatric medications requires specialist knowledge. The authorised psychiatrist should liaise with the general practitioner on a regular basis to ensure resident’s physical needs and any possible drug interactions are appropriately assessed and managed. Any disclosure of health information to general practitioners is governed by the confidentiality provisions in the Mental Health Act. See ‘Communication with other service providers’ for more details. Management of an identified physical health problem If a person is an inpatient at the time of diagnosis of a medical condition, referral may be made to the appropriate medical, surgical or specialist unit. Other options include referral to outpatient services after discharge or referral back to the person’s community medical practitioner. The person’s nominated community medical practitioner should be informed in a timely manner about any findings and referrals made (see ‘Communication with other service providers’). Most people in the community will receive medical health care through a general practitioner or other health care provider. If a person is not accessing medical health care, the mental health service should refer the person to an appropriate health care provider and offer the necessary support to help the person engage with the provider. Where this is not achievable, for example when a person is paranoid and refuses to access services, this should be documented in the clinical record and the person’s condition monitored for an opportunity to successfully refer them. Where a mental health service believes that a person is at significant risk due to their medical condition, reasonable steps should be taken to ensure prompt physical assessment, either by a medical practitioner from the mental health service or at an emergency department. If a patient under the Mental Health Act requires medical treatment and is unable to consent to the treatment, the authorised psychiatrist should consider using the powers for authorising non-psychiatric treatment in ss. 83–85 of that Act (see ‘Non-psychiatric treatment’). People should be educated and encouraged to minimise long-term health risks, with attention to issues such as smoking, obesity and exercise levels. Psychiatric treatment The authorised psychiatrist should consider a person’s medical needs in selecting psychiatric treatment options, preferentially selecting treatments that will not be affected by, nor affect, any known medical conditions. People should be actively monitored for side effects of treatment. Consent to physical examination or medical treatment Informed consent A person’s informed consent should be sought before any physical examination is performed or medical treatment is given. The common law requirements for full, free and informed consent generally apply. However, if the person is a patient (involuntary, security and forensic) under the Mental Health Act, the requirements for informed consent to non-psychiatric treatment in that Act apply (see ‘Nonpsychiatric treatment’). Issues for child and adolescent mental health services It is essential to gain consent or substitute consent (see below) before proceeding with a physical examination and any subsequent treatment involving a child or adolescent. People below the age of 18 years may be legally able to give consent, provided the young person has suffi cient intelligence and maturity to understand the nature and consequences of the examination or treatment and to make a decision. Wherever possible, parents and guardians should be involved in the decision. However, if a medical practitioner decides that a young person is competent to consent to an examination or treatment on his or her own behalf, the person’s right to confidentiality should be respected and permission should be obtained before these matters are discussed with a parent or guardian. Substitute consent If a person is unable to give informed consent to medical treatment, the laws governing substitute consent differ, depending on whether or not the person is a patient under the Mental Health Act and whether the person is an adult or a minor. Substitute consent for patients under the Mental Health Act If a patient under the Mental Health Act is unable to consent to non-psychiatric treatment (including both adults and minors), s.85 of that Act governs the process and lists the categories of people able to give substitute consent (see ‘Non-psychiatric treatment’). Substitute consent for other people If a person over the age of 18 years is unable to consent to medical treatment, substitute consent can be given by a medical treatment agent appointed under the Medical Treatment Act 1988 or a guardian or an enduring guardian appointed under the Guardianship and Administration Act 1986, where the agent or guardian has the power to make decisions about the proposed treatment. If the person does not have a medical treatment agent or guardian, part 4A of the Guardianship and Administration Act provides a substitute consent regime for medical and dental treatment. Generally, a spouse, primary carer or close relative can give consent to medical or dental treatment on their behalf if the treatment will be in the person’s best interests. Information explaining these provisions is available from the Public Advocate’s website If a person under the age of 18 years is unable to consent to medical treatment, a parent or an appointed guardian or custodian who has the power to make decisions about the proposed treatment may generally give consent. Consent in urgent situations Consent is not required where medical or dental treatment (in the case of a patient under the Guardianship and Administration Act) or non-psychiatric treatment (in the case of a patient under the Mental Health Act) is necessary, as a matter of urgency:
Communication with other service providers Mental health services should communicate with providers of physical health care to optimise management of a person’s mental and physical health care needs. Generally, the service should seek the person’s consent for the disclosure of information. Most people will agree to giving information to other treating clinicians or services if time is taken to discuss the reasons and the benefits, although they may wish to place limits on the disclosure of some information, particularly sensitive information. These wishes should generally be respected. Section 120A(3)(e)(i) of the Mental Health Act permits disclosing information without consent where this is required for the ‘further treatment’ of a person with a mental disorder. The purpose of this exception to confidentiality is to facilitate continuity of treatment between different agencies or services that provide treatment and services to an individual. Examples include the disclosure of information to a general practitioner who is supervising the treatment of a person subject to a community treatment order and the disclosure of information to an organisation providing psychiatric disability and rehabilitation support services (PDRSS) to a person. Only information that is necessary for the continuing treatment of the person’s mental disorder should be disclosed under this exception. In particular, discharge summaries should not be routinely sent to general practitioners or other service providers unless the person consents or it is necessary to facilitate continuity of treatment and the requirements of s.120A(3)(e)(i) are met. Where a clinician decides to disclose information to another clinician or service under this provision, it would be good clinical practice to inform the person. Generally, only where this would pose a risk to the health or welfare of any individual should the person not be informed. Mental health services should generally liaise with the community practitioner when:
Section 87 of the Mental Health Act provides that:
The examination has two components: the psychiatric examination and the physical examination. Different medical practitioners may complete the different parts, for example, the person’s general practitioner may perform the physical examination. The authorised psychiatrist is responsible to ensure both the psychiatric and physical examinations are comprehensive and that any issues concerning the person’s health that are raised by the examinations are addressed. Consent issues The annual examination is required by the Mental Health Act and is integral to the patient’s psychiatric treatment. In particular, the requirement for a physical examination provides an opportunity to identify any medical conditions that may be affected by or might affect the patient’s mental illness. It also ensures any side effects of treatment can be identified and appropriately managed. If the person is unable to consent to the examination or unreasonably refuses to give consent, the authorised psychiatrist may consent on their behalf. Sometimes, patients on community treatment orders question the need for a physical examination and refuse to cooperate. In these circumstances, a patient should not be forcibly physically examined if they are strongly opposed to the examination. The reasons for the examination should be explained and reasonable efforts made to obtain the person’s cooperation. If a patient refuses to be physically examined, the relevant practitioner should summarise the person’s physical health to the extent that is possible and also document the circumstances of the refusal. If a patient refuses to be physically examined, this subject should be revisited from time to time to see if the person has changed their mind and to encourage the person’s cooperation. Documentation The results of the examinations should be recorded on the Annual examination of patient (MHA 32) form and promptly sent to the Chief Psychiatrist, usually within four weeks of the date of the annual examination. A copy of the person’s treatment plan (in the case of patient under the Mental Health Act) or equivalent plan should be attached. Service management should ensure a reminder system is developed and implemented to ensure annual reports are performed in a timely manner. An ‘annual examination report’ is available through the CMI/ODS to assist service providers to monitor the due dates for annual examinations. Introduction and scope The Mental Health Act establishes a regime for consent to non-psychiatric treatment for patients (involuntary, security and forensic) under that Act. The term ‘patient’ is used in this part of the guideline for this reason. The non-psychiatric treatment regime does not apply to people receiving mental health services on a voluntary basis. The common law requirements for full, free and informed consent to medical treatment apply to this group. If such a person is unable to consent to medical treatment, part 4A of the Guardianship and Administration Act provides a substitute consent regime for medical and dental treatment. If the person is under the age of 18 years and unable to consent to non-psychiatric treatment, a parent or an appointed guardian or custodian who has the power to make decisions about the proposed treatment may generally give consent. Definitions The Mental Health Act makes a distinction between ‘major non-psychiatric treatment’ and other types of ‘non-psychiatric treatment’. The requirements for informed consent for the two categories are different. Non-psychiatric treatment Non-psychiatric treatments are any of the following procedures where the primary purpose of the procedure is not the treatment of any mental disorder or the effects of mental disorder:
Non-psychiatric treatment does not include ‘special procedures’ or ‘medical research procedures’. These procedures are discussed later in this guideline. Major non-psychiatric treatment The Chief Psychiatrist defines the following non-psychiatric treatments to be ‘major non-psychiatric treatments’:
Informed consent to non-psychiatric treatment A patient’s informed consent should be sought before any non-psychiatric treatment is performed. The requirements differ according to whether the non-psychiatric treatment is major or not. Major non-psychiatric treatment The requirements for informed consent to ‘major nonpsychiatric treatments’ are that the person gives full, free and informed written consent after:
In addition, the person must be given the patients’ rights booklet Major non-psychiatric treatment and the information explained. If the person appears not to have understood the explanation, arrangements must be made to convey the information to the person in the language, mode of communication or terms that the person is most likely to understand. Other non-psychiatric treatment There are many minor procedures, investigations and courses of medication that do not fall within the definition of ‘major non-psychiatric treatment’, but which still fall within the definition of non-psychiatric treatment. The requirements for informed consent to these other nonpsychiatric treatments, which are not ‘major non-psychiatric treatments’, are that the person gives full, free and informed consent after:
Informed consent by patients under 18 years of age Patients below the age of 18 years may be legally able to give consent to non-psychiatric treatment, provided the young patient has sufficient intelligence and maturity to understand the information that must be given under the requirements for informed consent above and make a decision about the treatment. Wherever possible, parents and guardians should be involved in the decision. However, if a medical practitioner decides that a young patient is competent to consent to treatment on his or her own behalf, the patient’s right to confidentiality should be respected and permission should be obtained before the proposed treatment is discussed with a parent or guardian. Consent to non-psychiatric treatment where a patient is incapable of giving informed consent If a patient is incapable of giving informed consent, the Mental Health Act sets out a process and lists the categories of people able to give substitute consent on behalf of the patient. Substitute consent for a patient 18 years of age or over If an adult patient is incapable of giving informed consent to any non-psychiatric treatment (including ‘major nonpsychiatric treatment’), consent may be given by the first person listed below who is reasonably available, willing and able to make a decision about the proposed treatment:
Substitute consent for a patient under 18 years of age If a patient under the age of 18 years is incapable of giving informed consent to any non-psychiatric treatment (including ‘major non-psychiatric treatment’), consent may be given by any of the persons listed below who is reasonably available, willing and able to make a decision about the proposed treatment:
Consent by the authorised psychiatrist Where the authorised psychiatrist proposes to consent to a non-psychiatric treatment on behalf of a patient, he or she should be satisfied that the treatment is in the best interests of the patient. Some matters that the authorised psychiatrist could take into account when deciding whether a non-psychiatric treatment would be in the best interests of a patient include:
In order to protect the personal autonomy of the patient, the authorised psychiatrist should always consider whether the proposed non-psychiatric treatment could await the person’s recovery so that the patient can decide whether or not to consent to the proposed treatment. The authorised psychiatrist should obtain a second opinion where a proposed non-psychiatric treatment involves significant risk or where the patient or a family member strongly objects to the proposed treatment. Non-psychiatric treatment if an appointed substitute decision maker refuses consent If an appointed agent or guardian refuses to give consent to a necessary non-psychiatric treatment, the authorised psychiatrist may consider making an application to the Guardianship List of VCAT for a review of the decision to refuse the treatment, and of the relevant guardianship order or enduring power of attorney (medical treatment). The authorised psychiatrist should only consider making an application if he or she believes on reasonable grounds that the proposed treatment is necessary and in the best interests of the patient. If a parent, guardian or custodian of a patient under the age of 18 years refuses to consent to a necessary nonpsychiatric treatment, the authorised psychiatrist may seek advice and referral from the Office of the Public Advocate. There is a power to challenge the decision in a court where it is believed the parent, guardian or custodian is not acting in the best interests of the child. Consent in urgent situations Consent is not required where a non-psychiatric treatment is necessary, as a matter of urgency:
Non-psychiatric treatment after an involuntary treatment order is made When an involuntary treatment order is made for a person, the authorised psychiatrist must examine the person within 24 hours to decide whether or not to confirm the order. During this period the authorised psychiatrist should not consent to any non-psychiatric treatment without first having examined the person. If a person is incapable of consenting to non-psychiatric treatment during this period, a medical treatment agent, guardian, enduring guardian or other appointed substitute decision maker may consent, as described above. If any non-psychiatric treatment is necessary as a matter of urgency, no consent is required and the treatment may be given as described in ‘Consent in urgent situations’ above. Medical Treatment Act continues to apply A medical practitioner must not carry out any nonpsychiatric treatment, including any urgent treatment (see ‘Consent in urgent situations’ above), if the medical practitioner knows that a ‘Refusal of treatment certificate’ has been completed and is in force in accordance with the Medical Treatment Act. Further information is available from the Office of the Public Advocate on 9603 9500, 1300 309 337 (toll free) Documentation Consent forms Informed consent for a ‘major non-psychiatric treatment’ is recorded on an Informed consent to major non-psychiatric treatment (MHA 26) form. Informed consent for any non-psychiatric treatment that is not ‘major’ does not need to be in writing. However, the rationale for the decision to prescribe a non-psychiatric treatment and the details of the process for obtaining informed consent must be recorded in the patient’s clinical record. Where service providers wish to obtain written consent to these non-psychiatric treatments, locally developed consent forms may be used. Substitute consent for any non-psychiatric treatment (including ‘major non-psychiatric treatment’) is recorded on a Substitute consent to non-psychiatric treatment (MHA 27) form. Register of major non-psychiatric treatment The authorised psychiatrist of each approved mental health service must establish and maintain a register of each ‘major non-psychiatric treatment’ performed on a patient of the service (Register of major non-psychiatric treatment (Schedule 21)) - Oct 2008. A copy of each written consent to a ‘major non-psychiatric treatment’ must be attached to the register. The register should be retained at the mental health service and be available for inspection on request by the Chief Psychiatrist or delegate. General documentation requirements In addition to the statutory requirements for documentation, good clinical practice requires that the clinical record show documentation of the requirements of professional standards of practice, guidelines and relevant local policy and procedures, including:
Appointed substitute decision makers At the time when a patient requires non-psychiatric treatment, it is sometimes unclear whether the person has a substitute decision maker who can make a decision about the proposed treatment. Mental health service providers should routinely record at the time of admission or intake whether a patient has a guardian or has appointed any person to be their enduring power of attorney (medical treatment) or their enduring guardian. Special procedures Special procedures are medical treatments that by their nature are so intrusive or serious that they require special regulation by legislation. The Guardianship and Administration Act governs consent to special procedures for ‘patients’ within the meaning of the Guardianship and Administration Act. In this part of the guideline, the term ‘patient’ refers to patients under the Guardianship and Administration Act. Definition ‘Special procedures’ are defined in the Guardianship and Administration Act as:
Consent to a special procedure for a patient 18 years of age or over A person must give informed consent to the performance of a special procedure. The authorised psychiatrist may seek a second psychiatric opinion if there is any doubt about whether a person has the capacity to give informed consent to a special procedure. If a patient is incapable of giving informed consent to a special procedure, the procedure may be performed with the consent of VCAT. A guardian, agent or authorised psychiatrist cannot consent on the person’s behalf. A person is considered to be incapable of giving consent if the person is either:
The ‘person responsible’ for a patient, or any person who has a special interest in the affairs of the patient, can make an application to VCAT for consent to carry out a special procedure.27 Application forms and advice are available from the VCAT website or by calling 9628 9911 or 1800 133 055 and asking to speak to the Guardianship List Registrar. VCAT may only consent to the carrying out of a special procedure if it is satisfied that:
If VCAT gives consent to a special procedure, it may authorise the ‘person responsible’ to consent to continuing the special procedure or carrying out any further special procedures of a similar nature. Consent in urgent situations A special procedure may be performed without consent if the procedure is necessary, as a matter of urgency:
Register of major non-psychiatric treatment The Chief Psychiatrist requires that the authorised psychiatrist enter the details of any special procedures performed in relation to patients (involuntary, security and forensic) under the Mental Health Act in the (Register of major non-psychiatric treatment (Schedule 22)). Special medical procedures for children The Guardianship and Administration Act, and the procedures for obtaining consent to a special procedure, do not apply to children (up to 18 years of age). Some medical procedures proposed for children require the approval of the Family Court of Australia. These procedures include non-therapeutic sterilisation, gender reassignment and donation of non-regenerative tissue. A parent or guardian cannot consent to these special medical procedures. If a special medical procedure is being considered for a child, information and assistance should be obtained from the Offi ce of the Public Advocate. A guideline titled Special medical procedures for children is available on the Public Advocate’s website Medical and psychiatric research Introduction Part 4A of the Guardianship and Administration Act establishes the regime governing the carrying out of ‘medical research procedures’ (including psychiatric research) on people who are incapable of consenting to these procedures. It provides a four-step process for authorising the carrying out of medical research procedures on ‘patients’ within the meaning of that Act. A ‘patient’ is a person with a disability (intellectual impairment, mental disorder, brain injury, physical disability or dementia) who is 18 years of age or over and is incapable of giving consent to the carrying out of a medical research procedure. In this part of the guideline, the term ‘patient’ refers to patients under the Guardianship and Administration Act. A person is considered to be incapable of giving consent if the person is either:
The authorised psychiatrist may seek a second psychiatric opinion if there is any doubt about whether a person has the capacity to give informed consent to the performance of a medical research procedure. Further information available by downloading complete document For further information about general health and non-psychiatric treatment contact the Chief Psychiatrist on 1300 767 299 or 9096 7571. For information about special procedures contact the Guardianship List on 9628 9911, 1800 133 055 (toll free) or www.vcat.vic.gov.au, or the Offi ce of the Public Advocate on 9603 9500, 1300 309 337 (toll free) or www.publicadvocate.vic.gov.au For information about medical research procedures visit the Public Advocate’s website or contact your local human research ethics committee. Additional information is available on the Department of Human Services’ website at www.health.vic.gov.au/legislation/medicalresearch.htm Electronic copies of the Mental Health Act and the Guardianship and Administration Act can be viewed or downloaded from the legislation and parliamentary documents website www.legislation.vic.gov.au About Chief Psychiatrist's guidelines The information provided in this guideline is intended as general information and not as legal advice. Mental health service management should ensure that policies and procedures are developed and implemented to enable staff to assess and manage the physical and medical needs of people and, where required, to obtain and document valid consent for medical treatment, non-psychiatric treatment, special procedures and medical research procedures. If mental health staff have queries about individual cases or their obligations under the Mental Health Act or the Guardianship and Administration Act, service providers should obtain independent legal advice. |
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Last updated:
24 October, 2008
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