The ethical and legal dilemmas paramedics face when managing a mental health patient

Assessing for a physical cause

Harris and Millman (2011) highlight the importance of ruling out a physical cause for the patient presenting with altered mental status such as hypoglycaemia, head injuries, infection and alcohol or drug use. Some of these are easier to address in the pre-hospital environment than others, for example, a simple blood glucose and temperature check excluded hypoglycaemia and lowered the index of suspicion for infection, as John had a normal temperature and blood sugar level. He wasn't known to have sustained a head injury, nor taken any alcohol or drugs. There were no obvious physical causes for John's behaviour at this stage. Consequently, the crew began to assess for a psychological cause.

Assessing for a psychological cause

Berry (2014) and Roberts and Henderson (2009) found that a large number of paramedics feel that they are undertrained and possibly underequipped to effectively assess and manage mental health conditions. However, the crew were able to identify some typical symptoms of psychosis in Johns' behaviour. The term ‘psychosis’ can be used as an umbrella term for a number of different psychotic disorders (NICE, 2014) and so will be utilised here due to the lack of specific diagnosis present for John. According to Harris and Millman (2011), in the earlier stages of schizophrenia, a chronic form of psychosis, the patient is likely to behave in a bizarre manner that is out of character to them, as was true of John. John's speech was also disordered; he regularly halted sentences mid-flow and appeared confused, completely losing fluidity and continuity of his passages. This is a condition referred to as ‘alogia’ or ‘poverty of speech’ and is another sign of psychosis (Turner, 2009; Harris and Millman, 2011; Kleiger and Khadivi, 2015). John spent most of his time standing, staring into space during the crew's presence, a further sign associated with psychosis, where patients spend extended periods of time seemingly doing nothing (Turner, 2009).

Although, hallucinations, delusions etc. are more commonly known symptoms of psychosis, the symptoms demonstrated by John fall within the six ‘hallmark’ features of psychosis as described by Kleiger and Khadivi (2015). In addition, due to John's virtually complete lack of speech, it was excessively difficult to ascertain if he was suffering any hallucinations/delusions at that time. This can be a common complication in psychosis and is frequently exacerbated by the effects psychosis has on a person's levels of trust, insight and the ability to rationalise, making them reluctant to share information (Kleiger and Khadivi, 2015). Having considered the probability of causes for John's symptoms, the crew suspected John may have been suffering from psychosis.

Assessing risk

The ambulance crew's concerns for John's welfare prompted them to assess his level of risk to self and others. John scored low risk on the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) self-harm and suicide assessment tool (JRCALC, 2006), but could still be vulnerable to other dangers such as neglect or accidental involvement in incidents such as walking out in front of cars when in a confused state (Azakan and Taylor, 2009). These risks seemed higher in John's case as he appeared somewhat detached from reality, as is true in psychosis (Kleiger and Khadivi, 2015), and so oblivious to the risks around him.

It is clear from these assessments that there are consequent physical risks to the patient's wellbeing depending on the mental health condition(s) present. For example, a person presenting with suicidal thoughts may score higher on the JRCALC tool, and thus be at high risk of self injury, but at a lower risk of being involved in an accident, a risk which may be higher in a person suffering from psychosis. John's risk to the public must also be considered, which, in spite of public opinion, is not usually any higher in psychotic patients (Davies, 2009). Although John appeared calm, and wasn't behaving at all aggressively at that time, the acute state of psychosis can be unpredictable, and pose serious risks (Hawley et al, 2011). As such, making John secure was a priority.

In this case, John refused to engage with the ambulance crew leading the crew to consider both the MCA and the MHA to protect the patient's wellbeing without his consent.

Assessing capacity

The Department of Constitutional Affairs (2007) states that a person's ability to make decisions to protect themselves must always be in balance with their civil right to make such decisions. As such, John was assessed using the MCA (Department of Health, 2005) to ensure that he had the capability and right to make his own decisions. On assessment, John didn't appear to understand the information given to him, the decision he needed to make, and he was unable to retain or comprehend treatment plans or the risks of noncompliance. He was also unable to effectively communicate his decision making process. The ability to do the above forms key elements of an MCA assessment and suggests that John lacked capacity at that time (Department of Constitutional Affairs, 2007). A person may be deprived of their civil liberties in order to be provided with care or treatment that they are unable to consent to due to a lack of capacity, if is in their best interests (Ministry of Justice, 2008; Amblum, 2014). This may be necessary to protect a person from harm or to prevent a deterioration in their condition (Department of Health, 2005).

With this considered, it appears that in John's case, the MCA would have been an appropriate means with which to act in John's best interests and convey him to a place of safety for further treatment, which would most likely have been the nearest emergency department.

Using the Mental Capacity Act

Unfortunately, in this case, it was wrongly thought by the crew that the MCA could not be used to enforce treatment plans for mental health conditions. However, the Department of Health (2015) clearly state that it is, so long as the patient hasn't already had their liberties removed under the MHA (1983). The code of practice for the MCA (Department of Constitutional Affairs, 2007) doesn't clearly set out which specific treatments may or not be provided under the MCA; however, it does seek to explain the relationship between the MHA and MCA. The MHA already provides the provision for the appropriate clinicians to provide medical treatment for mental health disorders without consent, whether the patient has capacity or not. Therefore, where appropriate, the MHA is likely to take precedence over the MCA where a patient is being treated for a mental health disorder. However, in the emergency setting, where a patient is only temporarily detained (either under section 4, 5 or 136 of the MHA) and awaiting further assessment, the patient cannot yet be treated without consent under the MHA.

In this case, the MCA can be applied in the normal way, to provide treatment, even if for mental health disorders, should the person lack capacity (Department of Constituational Affairs, 2007). Health care professionals may be more likely to use the MCA to enforce treatment should they consider the patient unlikely to meet the threshold for detention under the MHA. However, if a person seems likely to be detained under the MHA, decision-makers cannot “normally” (p.234) rely on the MCA to give treatment for, or make decisions about, a mental health condition. It is not clear though, how professionals (especially those who do not use the MHA) are likely to know in advance if a patient is likely to meet threshold for detention under this act, and so whether the MCA seems appropriate for use or not. This seems like a confusing area and it is unsurprising that paramedics report feeling unsure of exactly how to assess and utilise the capacity act (Amblum, 2014).

It seems that deciding which act is most appropriate must be managed on a case-by-case basis factoring in issues such as access to healthcare professionals available to utilise the MHA (as paramedics do not have it), the likely cause of the persons behaviour (physical/psychological), whether the patient seems likely to meet the threshold for detention under the MHA, and equally whether the patient is likely to be assessed as lacking capacity under the MCA. It seems paramount that whichever decision is made and Act is used, should the patient receive any form of involuntary treatment, the principles of the MCA and the MHA are upheld, and any decision made is in the patients best interest (Department of Health, 2005).

Using the Mental Health Act 1983

Due to this misconception, the crew then considered the MHA (1983). The Mental Health Act (1983) The MHA can be used to provide treatment for mental health disorders without consent (Department of Constitutional Affairs, 2007). In the UK, paramedics are currently not able to utilise any part of the MHA, though it is debated whether this would be beneficial (Berry, 2014; DOH, 2014). That said, given the earlier acknowledgment of paramedics feeling undertrained to assess mental health patients (Roberts and Henderson, 2009; Berry, 2014) it could be questioned how equipped paramedics would be to utilise this act. Interestingly, in some Australian states, paramedics have been granted powers under their MHA to detain mentally ill patients who require involuntary treatment (Parsons and O'Brien, 2011). Townsend and Luck (2009) state that these additional legislative powers have actually led to more confusion for paramedics attempting to manage mental health patients, advocating the need for further training in order to grasp a better understanding of the ethics and law involved. It doesn't seem clear yet within the literature, whether the addition of extra powers under legislation is of benefit or not. However, in this case the crew on scene were unable to utilise any sections of MHA, nor could they arrange for an MHA assessment by other professionals. This was because of current UK law and a lack of access to a GP respectively. Consequently, the crew had to consider alternative management plans for John.

The police

The police, however, do have the power to utilise section 135 and 136 of the MHA (1983). Section 136 allows a police officer to remove a person from a public place to a place of safety if they believe them to be suffering from a mental health condition and at risk of harm to themselves or others (Hawley et al. 2011). There is currently some debate as to whether the police are the most suitable personnel to be detaining patients under the MHA for a variety of reasons, and paramedics are mentioned as a potential alternative group to utilise this law in the future (Department of Health, 2014). At this time, using police powers seemed to be the last option available to ensure John's safety and treatment. Therefore, John was detained under this section and transported to the nearest 136 suite for further assessment and treatment. It seems important to note that had John been in a private place, this option would have been void, which may have presented an even more complex situation to manage safely and legally. This highlights the importance of having a good understanding of the MCA, as this is not limited by the persons whereabouts. Other sections of the MHA can be utilised to remove a person from their property but require further input from other professionals ranging from magistrates to psychiatric doctors and approved mental health professionals (see appendix 2). The use of the other sections of the MHA can require much more time (Hawley et al. 2011b) and it didn't seem that John could have kept himself safe until such a time he could have been detained in this way.

Additional powers: do we need them?

With regard to the addition of powers under the MHA for paramedics, Berry (2014) argues that the MCA (2005) should be sufficient for paramedics to manage mental health patients and where needed deprive them of their liberties, however the act appears to be neither sufficiently understood nor utilised and requires the patient to lack capacity, which is complex to assess and often present in mental health cases. Indeed, there is an argument that if we are to expect an improvement in the way emergency services manage mental health presentations and safeguard a vulnerable patient group, emergency services must be provided with the relevant tools and training to do so (Brown, 2014). In these complex cases with so many variables, it can sometimes be difficult to ‘fit’ patients in-between the lines of any law, often meaning that when decisions are unclear, paramedics are forced to engage in a risk management strategy without the power or provision of involuntary sectioning (Palmer, 2011). That said, we must not forget the potential for the additional confusion seen overseas once given access to further legislative powers (Townsend and Luck, 2009).