DD (Medical Consent)
[2009] TASGAB 8
•20 April 2009
GUARDIANSHIP AND ADMINISTATION BOARD
HOBART
D, on the application of Dr N
Neutral Citation: DD (Medical Consent) [2009] TASGAB 8
REASONS FOR DECISION
Catherine Wilding (Board Member)
20 April 2009
Consent to medical treatment – application for consent to treatment with antipsychotic drugs – notice of hearing – reasons for urgency to dispense with notice – person with a ‘proper interest in the matter’ – disability – capacity to understand nature and effect of treatment – wishes of the person – best interests
Guardianship and Administration Act 1995 – ss. 6, 36(1), 44(1), 45(1), (2) and (4), 69(1) and (3),
Guardianship and Administration Regulations 2007 – reg. 9(f)(ii)
On 6 April 2009 Dr N, made application for the medical treatment of Ms D, a patient at the Psychiatric Intensive Care Unit at the Royal Hobart Hospital (PICU). Dr N’s Application and Health Care Professional Report (as one document) were received by facsimile. Dr N’s application stated that a hearing was required urgently because Ms D had untreated psychosis predisposing her to refractory illness and prolonged recovery. Further, Dr N stated that Ms D had suffered with delusions of poisoning in the past, although she was currently eating and drinking.
Dr N applied for consent to medical treatment for Ms D with the following regime:
(i)Risperidone Consta up to 50mg by intramuscular injections fortnightly; and
(ii)Risperidone quicklets up to 2mg orally twice a day.
OR
(i)Zuclopenthixol acetate (Acuphase) 75mg by intramuscular injections every third day; and/or
(ii)Haloperidol 10mg by intramuscular injections.
AND
(i)Benztropine up to 2mg by intramuscular or intravenous injections up to three times per day for EPSE.
A hearing was convened on short notice pursuant to section 69(3) of the Guardianship and Administration Act 1995 (the Act) on the 7 April 2009.
Ms D is a 34 year old woman. The application has Ms D’s address and her mother, Ms XG, as the same, however it is understood Ms D resided with friends. Ms D said during the hearing that she “would rather not be represented by her mother” and there appeared no other immediate family or any person who might be able to undertake the role as ‘person responsible’ for the purposes of Part 6 of the Act. The application noted that the home phone number was called, however was engaged and a message was left. Ms XG she did not attend the hearing.
Ms D said that her admission was triggered by the mysterious disappearance of her father. Ms D was adamant she did not have schizo affective disorder nor any other medical problem apart from anxiety. At the time of the hearing Ms D was in PICU as an involuntary patient subject to a continuing care order under the Mental Health Act 1996.
Section 69 (1) of the Act requires that not less than 10 days notice of a hearing be given to people involved in it. The parties did not receive 10 days notice of the hearing. It was considered proper to dispense with the notice period by reason of urgency based on Dr N’s evidence at the hearing. Specifically, Dr N stated that an order was required by reason of urgency because the longer Ms D is psychotic, the harder it is to treat, with the upshot being that she would be suffering brain damage whilst untreated. Dr N said that Ms D was currently acutely ill. It was determined that it was appropriate to proceed with the hearing for reasons of urgency in accordance with section 69(3) of the Act.
Section 44(1) of the Act: It was determined that Dr N, as the applicant, had a proper interest in the matter because he was currently Ms D’s treating doctor.
Section 45(1)(a): When administered with consent, the administration of the proposed treatment is lawful.
Section 36(1): I accepted Dr N’s evidence that Ms D was a person with a disability for the purposes of this section. Dr N in his application detailed that Ms D has had a diagnosis of schizo affective disorder for 10 years and that she was admitted to PICU due to paranoid delusions that a friend is involved in the mysterious disappearance of her father. Dr N further noted that Ms D had illogical reasoning and that she was currently psychotic, paranoid, lacks insight and refuses to take an adequate treatment dose of anti-psychotic medication. Dr N did say however that it may be possible that Ms D’s diagnosis may change to one of schizophrenia and now that the medical team had an opportunity to observe and treat Ms D in her current environment, a clearer picture of her condition would be possible.
At the hearing Ms D was quietly spoken and said she was frightened and felt she was in danger since her father disappeared earlier this year. Ms D said she felt safe at PICU. Ms D gave me a book of her poetry she had been writing and said that the reason the application had been made was because people had read her poetry and thought she was ill. She said she did not have schizo affective disorder, but had anxiety.
Ms D spoke of people at PICU accessing her personal effects in her locker, although she was reassured by the medical staff present that this was not the case. Ms D also spoke of people having access to her house and reading her poetry there.
The Unit Manager of PICU attended the hearing and gave evidence that although Ms D had times that she was “ok” during this admission, she had become more disorganised each day. He agreed with Dr N’s view of Ms D’s disability.
I concluded that Ms D was a person with a disability for the purposes of this section based on the evidence of Dr N, the Unit Manager and my observations of Ms D at the hearing, which were consistent with Dr N’s opinion that Ms D was currently paranoid and lacked insight into her illness.
Section 45(1)(b): I accepted Dr N ’s evidence of Ms D’s disability and incapacity to make reasonable decisions about treatment for the purposes of section 36(1) and 45(1)(b) of the Act in that, because of her denial of the illness, she is unable to understand the nature and effect of the treatment or to reasonably give or refuse consent. Ms D, at the time of the hearing was, in the opinion of Dr N, which I accepted, acutely ill, namely psychotic and as a result, incapable of giving consent to treatment.
Dr N in the application stated that Ms D does not trust psychiatric staff and believes they mean to cause her harm.
When I asked Ms D about the treatment Dr N proposed, she said she was happy to take Seroquel, but refused to take Risperidone, stating the latter drug made her “unhappy.” Dr N stated that Ms D had been hospitalised for 2 weeks and the night before the hearing was the first time Ms D took her medications. This was borne out on the medication chart. Despite this, at the hearing, Ms D continued to assert that she suffered with anxiety, and would only take Seroquel.
Based on the above evidence, I concluded that Ms D was incapable of giving consent to the treatment regime proposed by Dr N.
Section 6 and 45(2)(a): Ms D’s stated wishes were that she continues on Seroquel only.
Section 45(2)(b): The consequences to Ms D if the proposed treatment is not carried out are, according to Dr N, that she will suffer brain damage for every day she is not treated. As mentioned earlier the Unit Manager gave evidence of progressive deterioration of Ms D with respect to her organisation.
Further, Dr N says in his application that Ms D will require a longer period of hospitalisation while her current episode runs its course and she will suffer an impaired long term functional outcome.
Section 45(2)(c): The question of alternative treatments available to Ms D was discussed at the hearing. Dr N’s view was that Risperidone would give Ms D a better therapeutic outcome. Dr N said he thought a mix of the Risperidone injection and quicklets would give Ms D the best therapeutic outcome but wanted to have flexibility within the regime is this was not the case, hence the alternative medication; Acuphase. The use of Benztropine for acute dystonics (muscle stiffness) would address possible side effects of the medications used.
Dr N’s application revealed that voluntary treatment had been tried unsuccessfully for a long time (ten year history of schizo affective disorder).Compliance with treatment regimes has been an ongoing issue.
Ms D stated that she wanted to continue on Seroquel only, however Dr N’s evidence was that this was not the best treatment available for Ms D in her current situation.
Section 45(2)(d) The proposed treatment could not be postponed on the grounds that better treatment may become available. I accepted the evidence of Dr N that no new drugs were likely to become available in the near future and Ms D required urgent treatment.
Regulation 9(f)(ii): Dr N described the known risks associated with the treatment regime he proposed; namely mild sedation and lactation caused by a change in the prolactin level. He also stated the medications can cause muscle stiffness. This is why he included the drug benztropine as part of the regime, as this medication relieves the symptoms of muscle stiffness.
Dr N also said that patients are monitored closely for side effects and any adverse effects were quickly addressed by the treating team.
Section 45(1)(c): In light of the evidence contained within the application and received during the hearing I am satisfied that the proposed course of medical treatment would be in Ms D’s best interests for the purposes of section 45(1)(c) of the Act.
Section 45(4): The treatment will commence immediately because of the risk of brain damage, continued deterioration and suffering experienced by Ms D as borne out on the evidence outlined above.
A report at 3 months is sought because it is considered important for the Board to maintain visibility of the matter given Dr N’s view that the diagnosis may change, the different medication regimes proposed, and the possibility that once a firm diagnosis and appropriate treatment was in place, it is hoped that the Order may no longer be necessary. This is of course balanced against the long history of non-compliance, hence the duration of the Order.
THE BOARD consents to medical treatment for the patient comprising the prescription by a qualified medical practitioner and administration of the following medications:
Risperidone Consta up to 50 mgs fortnightly to be administered by intramuscular injection by a qualified health care professional, or
Risperidone Quicklets up to 2 mgs twice daily, or Zucholpenthixol Acetate (Acuphase), 75 mgs every 3rd day, and
Benztropine up to 2 mgs either by intramuscular injection or intravenously up to 3 times per day as needed for acute dystonics.
THE BOARD FURTHER ORDERS
That this consent remains valid until 6th April 2010.
That pursuant to s.45(4) of the Guardianship and Administration Act 1995 the treatment may commence immediately.
That the treating doctor provide a report to the Board 3 months after the commencement of treatment.
Catherine Wilding
Board Member
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