Les Consignes Médicales en Psychiatrie, définition législative et état des lieux bibliographiques

Abstract

IntroductionMedical instructions are a well spread practice among French psychiatric wards, yet they are non homogeneous. There is not even a univocal name to specify it. ObjectivesFrom a descriptive approach of the ordinary practice of medical instructions, we will make an operational definition for them. From there, we will look for its definition and delimitation through legislative, jurisprudence, and deontological corpus, and clarify its difference with a medical prescription. We will extend the bibliography by a medical search through the scientific literature and French guidelines. MethodsA review of the French Code de Santé Publique, the deontological code from the French Medical Order, the reports of the Contrôleur Général des Lieux de Privation de Liberté (the General Controller of Liberty Deprival Places), and the French jurisprudence. We proceeded with keywords. As for the medical bibliography, we looked through the scientific literature as well as in the French guidelines from the Haute Autorité de la Santé. ResultsWe found no legislative caracterisation of medical instructions. When mentioned, they are not considered as medical prescriptions, but rather as a medical practice, or general care strategy, which the doctor is (the only one) responsible for. The jurisprudence clearly delimits the liberty restrictions that are possible for a medical doctor to prescribe, in the context of a suicidal risk. The CGPL reports point at various use of the “care framework” as a reason to limit the freedom of movement, without a proper medical necessity. The guidelines mostly raise the difficulty at stake with this practise (in terms of scientific validation and ethics), rather than suggesting the modality of its use. Medical literature does not provide focused studies on medical instructions. They do reveal their uses, and we have found several paramedical authors addressing them. DiscussionMedical instructions are a difficult object to study with the methodology of Evidence Based Medicine, because they are not quantifiable. Epistemological work could bring us some insight over this very contemporary practise. Alongside of which, case report studies are necessary to underline the different problematics at stake through the various systems they imply: the doctor-patient one, the doctor-staff and the staff-patient ones. Our bibliographic review has revealed how medical instructions are a singular object, from one prescriber (the doctor) but supported by teamwork and moreover permitting its coherence, its effectiveness. ConclusionWe have arrived to an operational definition of medical instructions: they are a medical order, with an individual therapeutic aim, that the staff has to execute, also the patient has a right to refuse it (like all treatment, emergencies aside). Medical instructions are not a law (that could lead to punition), nor an internal regulation (it is not general but individually thought), and neither a simple advice (the staff is bound to execute it). Medical instructions are a practical entry point to study the broader “care framework” that conditions the practice of institutional psychiatric care. We believe a good practise of medical instructions has to be reflected on, through regular Multidisciplinary meetings, inclusive of the different health care professionals involved: so they can be evaluated properly, and benefit from a comprehensive execution.