Abstract
BackgroundIn the UK, crisis planning for mental health care should acknowledge the right to make an informed advance treatment refusal under the Mental Capacity Act 2005. Our aims were to estimate the demand for such treatment refusals within a sample of service users who had had a recent hospital admission for psychosis or bipolar disorder, and to examine the relationship between refusals, and service user characteristics.MethodsTo identify refusals we conducted content analysis of Joint Crisis Plans, which are plans formulated by service users and their clinical team with involvement from an external facilitator, and routine care plans in sub-samples from a multi-centre randomised controlled trial of Joint Crisis Plans (plus routine mental health care) versus routine care alone (CRIMSON) in England. Factors hypothesised to be associated with refusals were identified using the trial data collected through baseline interviews of service users and clinicians and collection of routine clinical data.ResultsNinety-nine of 221 (45%) of the Joint Crisis Plans contained a treatment refusal compared to 10 of 424 (2.4%) baseline routine care plans. No Joint Crisis Plans recorded disagreement with refusals on the part of clinicians. Among those with completed Joint Crisis Plans, adjusted analyses indicated a significant association between treatment refusals and perceived coercion at baseline (odds ratio = 1.21, 95% CI 1.02–1.43), but not with baseline working alliance or a past history of involuntary admission.ConclusionsWe demonstrated significant demand for written treatment refusals in line with the Mental Capacity Act 2005, which had not previously been elicited by the process of treatment planning. Future treatment/crisis plans should incorporate the opportunity for service users to record a treatment refusal during the drafting of such plans.Trial registrationISRCTN11501328 Registered 13th March 2008.
Highlights
In the United Kingdom (UK), crisis planning for mental health care should acknowledge the right to make an informed advance treatment refusal under the Mental Capacity Act 2005
In the United Kingdom (UK), health service users have the right under the Mental Capacity Act (MCA) 2005 to make an informed advance treatment refusal [2] when capacitous, regarding times when their decision-making
This study uses data from three overlapping study samples: (1) intervention group participants who completed the Joint Crisis Plans (JCPs) process (n = 221) and whose JCP could be assessed for refusals; and (2) the 424 patients whose Care Programme Approach (CPA) care plans were available for assessment for treatment refusals at baseline; and (3) those in the control group whose CPA care plans were available at baseline and follow up (n = 221)
Summary
In the UK, crisis planning for mental health care should acknowledge the right to make an informed advance treatment refusal under the Mental Capacity Act 2005. Studies of both facilitated psychiatric advance directives (f-PADs) in the US [5, 6] and Joint Crisis Plans (JCPs) in the UK [7, 8] show much higher rates of refusals, at around three quarters of participants completing a f-PAD [5] or JCP [8] These are structured research interventions in which an independent mental health professional facilitates a discussion about preferences for future care - including treatment refusals - with the service user and, in the case of the JCP, with professionals involved in his or her care [9]. One trial conducted since the introduction of the MCA 2005 of JCPs for outpatients with borderline personality disorder [10] showed a very high (90.2%) rate of refusals, but no comparison with the rate of refusals in the conventional treatment plan was made
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