QKE (Medical Consent)
[2009] TASGAB 24
•29 October 2009
GUARDIANSHIP AND ADMINISTRATION BOARD
HOBART
QKE, on the application of Dr David McDougall
GAB No. XXXX
QKE (Medical Consent) [2009] TASGAB 24
REASONS FOR DECISION
Catherine Wilding (Board Member)
29 October 2009
Application for consent to medical treatment – person refusing treatment – high risk of suicide – consideration of side effects – urgency for commencement of treatment
Guardianship and Administration Act 1995 s 44, 45, 69
On 14 October 2009 Dr David McDougall, made application for the medical treatment of QKE, a patient at the Department of Psychological Medicine at the Royal Hobart Hospital (DPM). Dr McDougall’s Application was received by the Guardianship and Administration Board via facsimile. Dr McDougall’s application stated that a hearing was not required urgently and accordingly the full period of notice required by section 69 was served.
Dr McDougall’s application revealed that QKE had multiple admissions since 2002 for treatment of schizophrenia. Dr McDougall’s stated that management of QKE’s medical condition had been difficult due to continued amphetamine abuse, non-compliance, poor engagement with services and peregrination to evade treatment.
Dr McDougall also wrote that QKE had been recently admitted following a large overdose of medications which caused renal impairment and that QKE suffered from ongoing psychotic symptoms at the time of his application, however that QKE was not acutely agitated.
Dr McDougall applied for consent to medical treatment for QKE with the following regime:
A choice of:
(i)Risperidone Consta up to 75mg by intramuscular injections
fortnightly;
OR
(ii)Zuclopenthixol decanoate up to 400mg monthly;
OR
(iii)Haloperidol depot up to 300mg monthly.
A hearing was convened on 29 October 2009.
QKE is a 48 year old man. The application noted that QKE does not give permission for “us” to talk to his mother and it appeared from the hearing there was no other person who might be able to undertake the role as ‘person responsible’ for the purposes of Part 6 of the Guardianship and Administration Act 1995 ( the Act).
Section 44(1) of the Act: It was determined that Dr McDougall, as the applicant, had a proper interest in the matter because he was currently QKE’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 McDougall’s evidence that QKE was a person with a disability for the purposes of this section. Dr McDougall in his application detailed that QKE was first diagnosed with schizophrenia in 2002 and that he was admitted to hospital on this occasion following a large overdose of a number of medications. Dr McDougall stated that treatment of QKE’s mental state had been historically poor, a contributing factor of which included substance abuse, not complying with prescribed medications and moving around the State. Dr McDougall stated that there was every indication that but for these factors; QKE would be responsive to treatment.
At the hearing QKE was legally represented. In addition, QKE clearly articulated his views and presented reasonably coherently. QKE stated that he had had all the drugs before and still ended up in hospital. QKE stated that his psychosis stopped last year after 4 years of not taking any drugs, with the effect of “burning itself out.” QKE said he was willing to take some medications however these were not the ones suggested by Dr McDougall, indicating that he suffered side effects he didn’t want if he took the suggested medications. QKE said he suffered from muscle rigidity and muscle locking when he took benztropine and went on to say he didn’t want any of the drugs that had been discussed as possible options by Dr McDougall during the hearing.
Dr McDougall said that people suffering side effects from medications wouldn’t necessarily continue on those medications and that there were ways of treating side effects suffered. Dr McDougall stated that if QKE wasn’t treated he would be at high risk of suicide and had already been admitted twice because of that risk. Dr McDougall said that untreated psychosis leads to suicidality. This was endorsed by the community nurse attending the hearing (Nurse D). Nurse D also supported the evidence given by Dr McDougall that there had been a problem treating QKE in the community because he was non compliant with his medications, he had no insight into his illness, he continued to self medicate and that he was, untreated, at a very high risk of suicide.
QKE denied assertions by the treating team that he “doctor shops”, but did agree that he uses amphetamines fortnightly when he gets his Centrelink payment. On these occasions QKE said he stayed at home and wrote, listened to music and was no threat to society because he just stayed at home when using drugs.
It was difficult to reconcile QKE’s coherent and measured presentation of his views against the medical evidence. However Dr McDougall’s evidence was clear that QKE showed a number of psychotic symptoms during the current admission, such as believing that he is being surveyed by other worldly beings.
On the basis of this evidence, together with the other medical evidence provided by Dr McDougall and Nurse D, I concluded that QKE was a person with a disability for the purposes of this section.
Section 45(1)(b): I accepted Dr McDougall ’s evidence of QKE’s disability and incapacity to make reasonable decisions about treatment for the purposes of section 36(1) and 45(1)(b) of the Act because of his lack of insight into his illness. Also the fact that QKE’s refusal to accept the therapeutic benefit of what is proposed by Dr McDougall, and his continued assertion that alternative medications ought be ordered when they were not recommended, demonstrated that QKE is unable to understand the nature and effect of the treatment or to reasonably give or refuse consent. QKE, at the time of the hearing was, in the opinion of Dr McDougall, which was accepted, psychotic and as a result, incapable of giving consent to treatment.
Based on the above evidence, I concluded that QKE was incapable of giving consent to the treatment regime proposed by Dr McDougall.
Section 6 and 45(2)(a): QKE stated that he did not want the treatment proposed by Dr McDougall and suggested an alternative regime that was not recommended by Dr McDougall. QKE stated that he wanted to undertake a residential rehabilitation program and said he objects to any order being made because he has capacity to consent or refuse medications and did not want the proposed medications because of the side effects.
Section 45(2)(b): The consequences to QKE if the proposed treatment is not carried out are, according to Dr McDougall, that QKE will be at a high risk of suicide, he will continue to suffer distressing effects of chronic schizophrenia, continue his drug use and all these factors will compromise the possibility of stabilizing his illness.
Section 45(2)(c): The question of alternative treatments available to QKE was discussed at the hearing as outlined above at paragraph 4. Dr McDougall also stated that QKE would be carefully monitored for any side effects from the medications used thus the alternative regime he suggested.
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 McDougall that QKE required urgent treatment because of his high risk of suicide.
Regulation 9(f)(ii): Dr McDougall 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 McDougall 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 QKE’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 suicide for QKE.
I considered the principle of finding the least restrictive alternative when considering the period of any substitute consent and concluded that in the circumstances that there should be enough time given to enable a period of stability for treatment and thus once a therapeutic benefit was obtained by QKE it is hoped that other things in QKE’s life would result, such as acceptable housing, gaining work, establishing an intimate relationship with a woman. These were all things that QKE expressed as desirable for him and we discussed the fact that they had previously evaded him given his choices around treatment which had directly impacted on his lifestyle.
I also made it very clear to QKE that I heard and understood what he said about side effects of medications proposed, but that in the absence of alternative medications that did not have such effects we were limited to use medications that currently exist and reiterated Dr McDougall’s assurance that QKE would be closely observed for any of theses effects and the treatment regime adapted to give QKE the best therapeutic outcome possible for him. The urgent need to keep QKE from suiciding was also made clear to QKE, thus the treatment was ordered to commence immediately.
As a result the following determination was made:
THE BOARD consents to medical treatment for the patient comprising the prescription by a qualified medical practitioner and administration by a qualified health care professional to administer Benztropine up to a maximum of 1 mg twice per day to be administered orally or by intramuscular injection, if required, for the treatment of extrapyramidal side effects and the administration of one of the following drugs:
Flupenthixol depot (fluanxol) up to a maximum of 80 mgs per fortnight, to be administered by intramuscular injection; or
Risperidone Consta up to 75 mgs fortnightly to be administered by intramuscular injection; or
Haloperidol depot up to a maximum of 300 mgs per month to be administered by intramuscular injection; or
Zucholpenthixol decanoate up to a maximum of 400 mgs per month to be administered by intramuscular injection.
THE BOARD FURTHER ORDERS
That this consent remains valid until 28th October 2010.
That pursuant to s.45(4) of the Guardianship and Administration Act 1995 the treatment may commence immediately.
Catherine Wilding
Board Member
0
0
0