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Royal Australian & New Zealand College of Psychiatrists Code of Ethics

Download Royal Australian & New Zealand College of Psychiatrists Code of Ethics (PDF 244Kb)

13 November 2009

 

Dr Nick Judson
Chair
Committee for Professional Practice
Royal Australian New Zealand College of Psychiatrists
Email: ethics@ranzcp.org

 

Dear Dr Judson

Re:      Code of Ethics ─ Stakeholder Consultation

Thank you for giving HDC the opportunity to comment on the revised Royal Australian and New Zealand College of Psychiatrists (RANZCP) Code of Ethics (Code of Ethics), which RANZCP intends to publish early in 2010.

I strongly support the RANZCP's goal of achieving "the best attainable quality of psychiatric care and mental health". I agree that cultivating and maintaining the highest ethical standards is vital to realising this vision, and retaining community trust in the profession.

General comments

In general, I found the Code of Ethics to be very good. However, there were some minor matters that in my view need clarification, in particular the language surrounding consent, and who may provide this in the case of a consumer who lacks competence.

While I appreciate that the Code of Ethics is also for Australian psychiatrists, references to "substitute consent", "valid consent" and "authorised substitute decision-makers" do not align well with terms used in the HDC Code, or to usage in New Zealand.  I suggest replacing references to "valid consent" with "informed consent".

In relation to the usage of "substitute consent" and "authorised substitute decision-makers", the HDC Code states that where a consumer is not competent to make an informed choice and give informed consent, consent may be sought from a "person entitled to consent on behalf of the consumer". It may be useful to amend the Code of Ethics to reflect this difference.

For example, sub-principle 4.4 currently states that "[w]here the patient is unable to understand the concept of confidentiality and its limits, substitute consent may be required". I suggest amending this statement to read that "[w]here the patient is unable to understand the concept of confidentiality and its limits, consent may be sought from a person entitled to consent on behalf of the patient". References to "authorised substitute decision-makers" should also be amended accordingly. For example, sub-principle 5.7 could be modified to state that "[w]here a patient does not have the capacity to provide consent, psychiatrists shall seek consent from a person entitled to consent on behalf of the patient".

I have made some specific comments and suggestions below for your consideration. I have also included valuable comments made by Judi Strid, Director of Advocacy.

Additional principle

Co-operation with other providers

In the period between 2004 and 2009, HDC received approximately 150 complaints involving psychiatrists. A significant number of complainants were concerned that psychiatrists had not co-operated with other providers to ensure continuity of care for patients, and had breached Right 4(5) of the Code, which provides that "every consumer has the right to co-operation among provides to ensure quality and continuity of services".

For example, Complaint 07/06672 involved Ms C, a young mental health consumer who complained about a change in diagnosis when she was admitted to a mental health unit. Ms C had a long history of mental health problems, and had previously been diagnosed as having a major depressive disorder. Dr C, a locum consultant psychiatrist, reviewed Ms C when she was admitted to the mental health unit, and concluded that she was not suffering from depression, but from a factitious disorder. The psychiatrist did not consult with the patient's clinicians prior to making the new diagnosis, and did not keep clear documentation outlining the reasons for his new diagnosis. While I made no finding in relation to whether Dr C's diagnosis was correct, I was concerned that he had not consulted his colleagues prior to making a diagnosis that was very different to the previous diagnosis, and resulted in a change in treatment. In these circumstances, I found that Dr C had breached Right 4(5) of the Code.

Complaints such as Ms C's highlight the need for co-operation and clear communication between members of multi-disciplinary teams in the mental health setting. To emphasise the importance of this, I suggest that the Code of Ethics include a principle stating that psychiatrists shall co-operate with other providers to ensure quality and continuity of services.

Principle one

It is good to see that the Code of Ethics contains a reference to relieving the "suffering of those whose autonomy is impaired through loss of capacity from mental illness".

Principle two

I note that the Code of Ethics states that sexual relationships between psychiatrists and their current and former patients are "always unethical". I applaud the unambiguous language.

I also note the statement in principle 2.4 that "any behaviour that might be reasonably interpreted by a patient as demeaning, or as a sexual advance, is unethical. Such behaviour may include physical contact, or conduct, comments or innuendo of sexual nature … that is not necessary for clinical purposes."  Complaints to HDC have highlighted the risk of treatment provided by psychiatrists being misinterpreted or misconstrued, particularly where consumers have presented with a history of sexual abuse.

Complaint 04/02840 involved a complaint from Ms A about the services provided to her by Dr A, a psychiatrist. Ms A, a consumer with a history of sexual abuse, had been undergoing psychotherapy sessions with Dr A.  She complained that in the course of her psychotherapy sessions with Dr A, he had sexualised their relationship" by making inappropriate comments and divulging personal details about himself to her.  I found that the techniques used by Dr A were based on well-established therapeutic principles and that Dr A had not breached the Code. However, it became apparent during my investigation that Dr A had communicated personal information about himself to Ms A, which she interpreted as a sexual advance. I accepted that Dr A had disclosed personal information about himself in the context of psychotherapy for sexual abuse and exploration of transference issues. However, I advised him that "the degree of disclosure of personal information … during the counselling sessions seem[ed] inappropriate".

Principle three

Principle three states that "psychiatrists shall provide the best attainable psychiatric care for their patients". I have three comments in relation to this principle.

First, I query whether this is a realistic expectation, without some qualification such as clause 3 of the HDC Code, which states that a "provider is not in breach of the Code if the provider has taken reasonable actions in the circumstances to give effect to the right, and comply with the duties, in this Code".

My second comment relates to the sub-principle that "psychiatrists may decline to accept the referral of patients when appropriate and justifiable". I consider that this statement requires clarification, such as:

"Psychiatrists may decline to accept the referral of patients when appropriate and justifiable so long as they ensure safe arrangements have been put in place that do not the patient at risk."

My third comment is about the statement in sub-principle 3.11 that "psychiatrists shall use evidence-based interventions wherever possible but appreciate that novel procedures and treatments may be indicated in certain clinical circumstances".  In my view, any innovative procedures and treatments which psychiatrists propose to use should be subject to appropriate ethics committee approval.  I also suggest that this sub-principle be amended to emphasise the need for active effort to be made to "reduce the use of restraint and seclusion … and that ECT should only be used as a last resort, and should not be used if the patient has made a valid advance directive stating ECT is not to be used".

Principle four

Principle four states that "psychiatrists shall strive to maintain confidentiality of patients and their families". This goal is qualified by sub-principle 4.3, which states that a

"breach of confidentiality may be justified on rare occasions in order to promote the best interests and safety of the patient or of other people. Psychiatrists may have a duty to inform the intended victim/s and/or relevant authorities."

I accept that this qualification is necessary.  

The issue of family involvement in the face of objections from a mental health consumer is example one.  Complaint 07/06607 involved a complaint about the care provided to Mr B at a public hospital in 2003-2004.  Mr B had been receiving mental health services since 1990, for a range of psychiatric disorders. He had a number of acute admissions during this period, and in January 2004, he was once again admitted to the inpatient unit at the public hospital.  At this time, he was assessed as being acutely psychotic, with a low risk of suicide and medium risk of violence and aggression. While he was initially admitted into the open ward of the public hospital, he was transferred to a secure unit a short time later, because of increased aggression towards hospital staff. Shortly after his transfer, Mr B committed suicide.

I investigated the complaint, and assessed the care provided to Mr B between 2001 and 2004.  One of the questions that arose during the course of the investigation was whether the hospital staff should have involved Mr B's family in his care, despite his express request to the contrary.  I conclude

"Mr [B] had made it clear that he did not want his family involved in his care. I acknowledge the importance of maintaining patient privacy. However … due consideration should be given to the part the illness may play in the attitude of the consumer when refusing family involvement."

In this case, the public hospital had a policy which emphasised the "involvement of family in providing quality treatment and support services" to mental health consumers.  There was scant evidence that involvement of Mr B's family and friends was ever thoroughly explored, a fact which suggested that the hospital's policy was not well known to staff. I considered that there "would certainly have been value in involving the family at the time of Mr [B's] discharge [and] staff should have explored involving the family, particularly in relation to the provision of ongoing support and crisis management".

Principle five

Sub-principle 5.1 states that "psychiatrists shall inform, and make sure that, the patient understands the purposes, nature, benefits, side-effects, risks and costs of a proposed procedure and treatment". Right 6 of the HDC Code entitles a consumer to the information that a reasonable consumer, in that consumer's circumstances, would expect to receive, including the purposes, nature, benefits, side-effects, risks and costs of a proposed procedure and treatment. Right 5 of the HDC Code also requires that this information be communicated to the consumer in a form, language, and manner that enables the consumer to understand the information provided.

I consider that sub-principle 5.1 is too strictly worded and does not accurately reflect the legal obligations incumbent upon providers. I suggest rewording sub-principle 5.1 to read

"psychiatrists shall inform, and seek to ensure that, the patient understands the purposes, nature, benefits, side-effects, risks and costs of a proposed procedure and treatment."

It may also be useful to add that psychiatrists should "encourage their patients to develop advance directives when they are well so their wishes will be known when they are unable to make decisions".  This is consistent with Right 7(5) of the HDC Code, which provides for consumers to "use an advance directive in accordance with the common law". However, I acknowledge that advance directives may not apply in a situation where a consumer has been placed under a Compulsory Treatment Order.

Conclusion

In summary, the principles set out in the Code of Ethics appear sound and will contribute positively to the delivery of psychiatric services to consumers. I trust my comments are of assistance, and would appreciate receiving a copy of the final version of Code of Ethics, when it is published in early 2010.

Yours sincerely

 

Ron Paterson
Health and Disability Commissioner

cc:        Judi Strid, Director of Advocacy

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