Further Review

The psychiatry registrar reviews the patient. Although the patient is not actively trying to leave, the registrar determines that he lacks capacity to sign into the hospital voluntarily and there is reasonable concern about the risk to others. The registrar discusses with the on-call psychiatrist who agrees. The registrar completes the paperwork to institute involuntary admission on the grounds that the patient presents a "danger to others". When the registrar attempts to engage him about taking antipsychotic medications, he re-fuses angrily, stating that there is nothing wrong with him. He cautions staff not to enter his "force field" and puts his hands up defensively.

Process of Review

The process of review under most Mental Health Acts begins with a review by qualified medical practitioners, after which there is generally an independent process of review conducted by a legal authority.

In NSW regardless of how patients are referred, they are then required to be seen by at least 2 medical practitioners, one of whom should be a Psychiatrist. The first review should occur within 12 hours.

A potentially confusing aspect of the NSW Mental Health Act is that there are actually 2 options for admitting a person under the Act. Both have their own separate definitions and rules.

In essence, Mentally Disordered is intended to be an option for a very time-limited detaining of a person where there may be some unspecified concerns about their well being. Whereas Mentally Ill is intended to be utilized where it is more clear that the person is suffering from a mental illness and may need a longer period of time in hospital.

Least Restrictive Care.

An important question to be considered when determining to admit someone to hospital is "Could we manage the person and the risk in another way or another setting?" This is an example of the principle of least restrictive care, which is an ethical principle derived from considering or balancing off the need to respect autonomy versus the need to ensure nonmaleficence (avoid harm) and also no harm occurs to others (justice).

We can justify the admission of an individual to hospital, including the overriding of their autonomy, on the basis that other ethical principles are more paramount at the time. For many patients, this time-limited restriction in autonomy can help to restore their autonomy, which provides another ethical justification. But this is not the case for all patients.

You will notice that we have not mentioned beneficence so far. The last ethical pillar. This is because whilst patients do have the right to timely, quality and effective treatment. This is not a justification in itself for involuntary admission. To do so would be an example of paternalism. Which is arguably the previous way we thought about involuntary treatment prior to least restrictive care.

The decision to admit involuntarily is a very gross example of least restrictive care. But there are also more granular decisions to be made about patients. Admissions to the hospital can be very restrictive or less restrictive. For example, the decision to grant a patient escorted leave whilst remaining an inpatient in the hospital would also be an example of applying the principle of least restrictive care.

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