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Concealment of medication in patients' food
CORRESPONDENCE
Concealment of medication in patients’ food Sir—Adrian Treolar and colleagues (Jan 6, p 62)1 discuss the practice of concealing patients’ medication in their food. In Hong Kong, the treatment of adults without mental capacity to give consent to urgent and non-urgent medical and dental treatment is governed by the Mental Health Ordinance,2 which became law on Feb 1, 1999. The merit of this new law is that it addresses the difficulties of the Bournewood judgment in the UK,3 by explicitly covering patients who cannot consent to treatment because of dementia or learning disability, and that it accepts that not all mentally incapacitated adults should be admitted before necessary treatment can be given. The law enshrines the principle that adults who are incapable of understanding the general nature and effect of treatment should not be deprived of treatment. Although these provisions are within the Mental Health Ordinance, the scope of inclusion is wide and covers groups of patients traditionally included in mental-health legislation and those with any other disorder or disability of mind, such as post-stroke or head-injured patients. To bring psychiatric and medical treatment under the same legislation makes sense, since they are similar ethically given that the aim is to relieve distress and improve health.1 In Hong Kong, how would the dilemma of “putting medicine in a cup of tea” be handled by clinical staff? Leaving aside the comparative merits of plain Chinese tea or the so-called British cuppa to help wash down medicine, for non-urgent treatment there seems to be three legal options. Consent can be obtained from a legally appointed guardian with the power to give proxy consent, or from the court, or staff can proceed without consent if they have taken reasonable steps to ascertain whether or not a guardian has been appointed. However, the ethics of giving medication covertly need to be discussed. Treatment may be justified if giving medication in this way represents the least restrictive alternative. Additional safeguards may be warranted for ethical and safe practice, including discussion with the family, as well as with the patient upon recovery if appropriate, and meticulous documentation to facilitate audit. In particular, continuity of care and rapport are indispensable. Finally, for patients who require complex
THE LANCET • Vol 357 • April 28, 2001
treatment, the physician in charge, rather than a psychiatrist or psychologist, would be best placed to explain to the patient the nature and effect of the treatment requiring consent. *Siew-eng Chua, Khai-meng Choy, Josephine Wong *Department of Psychiatry, University of Hong Kong, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong, SAR China; and Hospital Authority Building, Kowloon, Hong Kong (e-mail: [email protected]) 1
2
3
Treloar A, Philpot M, Beats B. Concealing medicine in patients’ food. Lancet 2001; 357: 62–64. Part IVC (Medical and dental treatment) Mental Health Ordinance (Chap 136). www.justice.gov.hk/blis.nsf/ (accessed March 14, 2001). R v Bournewood Community and Mental Health NHS Trust, ex parte L [1998] 3 AU England Reports 289 (HL).
Health system in Yugoslavia Sir—Entering a new era of democracy, the Yugoslavs are faced with operational difficulties and the need to restructure their whole health system. Until the 1990s the National Health Service in Yugoslavia covered, through local and regional taxation, the costs of healthcare. Access to medical specialists was easy and free, and referral rates were higher than in the UK. Hostilities and wars have, however, led to crisis. The UN sanctions, introduced in 1992–93, adversely affected the functioning of the health service1 and the national economy, and led to the influx of around 700 000, mostly Serb, refugees. Drugs and medical equipment could have been exempt from sanctions. However, the approval process was lengthy and required a consensus of all 15 members of the UN Security Council. Therefore, an acute shortage of drugs and medical equipment arose. The ban of all export-import transactions caused the economy to collapse, led to a high unemployment rate (27–49%), a striking decline in the standard of living, and the decrease of the average salary. The decline of the national income resulted also in cuts to the health budget. The shortage of drugs in state hospitals and pharmacies—in which drugs were provided free of charge— forced the population to purchase them in the private pharmacies that had started to open. Many patients could not afford the necessary drugs. Consequently, the rate of death from treatable diseases such as tuberculosis2 and infant mortality3 increased. The
number of patients rose by 7% because of the influx of refugees, which increased the need for medical aid and care. Despite these difficulties, Yugoslav doctors have worked hard. Liver and heart transplantations have been done since 1995; of 15 patients who underwent liver transplantation, 12 have survived for more than 2 years, which is comparable with western European standards.4 More liver transplants are, of course, needed in a population of more than 10 million, but, shortage of funds limits availability. When the sanctions were partly abolished in 1995, drug and equipment purchases became possible. However, the economic situation remained grave and funding and functioning of the health system remained a serious difficulty. Operational difficulties of the health system are especially notable in Serbia, which had to face further war and sanctions in 1998 imposed by the North Atlanatic Treaty Organisation. Health facilities were affected, some were even destroyed through bombing. The bombing of chemical-industry installations around Belgrade released toxic substances into the air,5 and longterm effects of such a pollution remain to be seen. Now, after the victory of its Democratic Opposition, Serbia (and Yugoslavia) is faced with reform, which is already underway. The large hospital services need to be reorganised and restructured to modernise their management. The financial participation of patients in the costs of healthcare services provided is expected to be introduced at the specialist level; therefore, more patients will probably be treated by family physicians. The Ministry for Health is to stop remuneration of hospital-board members and to cut the number of newly admitted medical students. Above all, however, hospitals need almost everything: drugs, diagnostic kits, new equipment, food, sheets, all those items that are indispensable for normal functioning. Slobodan Kazic Zvezdara Hospital, Dimitrija Tucovica 161, 11000 Belgrade, Yugoslavia (e-mail: [email protected]. ac.yu) 1 2
3 4 5
Black ME. Collapsing health care in Serbia and Montenegro. BMJ 1993; 307: 1135–37. Gledovic Z, Jovanovic M, Pekmezovic T. Tuberculosis trends in Central Serbia in the period 1956–1996. Int J Tuberc Lung Dis 2000; 4: 32–35. Litvinjenko S. Migration and health. Srp Arh Celok Lek 1997; 125: 191–96. European Transplant Register, 2000 (www.eltr.org/results). Ashford MW, Gottstein U. The impact on civilians of the bombing of Kosovo and Serbia. Med Confl Surviv 2000; 16: 267–80.
1369
For personal use. Only reproduce with permission from The Lancet Publishing Group.
Concealment of medication in patients’ food Sir—Adrian Treolar and colleagues (Jan 6, p 62)1 discuss the practice of concealing patients’ medication in their food. In Hong Kong, the treatment of adults without mental capacity to give consent to urgent and non-urgent medical and dental treatment is governed by the Mental Health Ordinance,2 which became law on Feb 1, 1999. The merit of this new law is that it addresses the difficulties of the Bournewood judgment in the UK,3 by explicitly covering patients who cannot consent to treatment because of dementia or learning disability, and that it accepts that not all mentally incapacitated adults should be admitted before necessary treatment can be given. The law enshrines the principle that adults who are incapable of understanding the general nature and effect of treatment should not be deprived of treatment. Although these provisions are within the Mental Health Ordinance, the scope of inclusion is wide and covers groups of patients traditionally included in mental-health legislation and those with any other disorder or disability of mind, such as post-stroke or head-injured patients. To bring psychiatric and medical treatment under the same legislation makes sense, since they are similar ethically given that the aim is to relieve distress and improve health.1 In Hong Kong, how would the dilemma of “putting medicine in a cup of tea” be handled by clinical staff? Leaving aside the comparative merits of plain Chinese tea or the so-called British cuppa to help wash down medicine, for non-urgent treatment there seems to be three legal options. Consent can be obtained from a legally appointed guardian with the power to give proxy consent, or from the court, or staff can proceed without consent if they have taken reasonable steps to ascertain whether or not a guardian has been appointed. However, the ethics of giving medication covertly need to be discussed. Treatment may be justified if giving medication in this way represents the least restrictive alternative. Additional safeguards may be warranted for ethical and safe practice, including discussion with the family, as well as with the patient upon recovery if appropriate, and meticulous documentation to facilitate audit. In particular, continuity of care and rapport are indispensable. Finally, for patients who require complex
THE LANCET • Vol 357 • April 28, 2001
treatment, the physician in charge, rather than a psychiatrist or psychologist, would be best placed to explain to the patient the nature and effect of the treatment requiring consent. *Siew-eng Chua, Khai-meng Choy, Josephine Wong *Department of Psychiatry, University of Hong Kong, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong, SAR China; and Hospital Authority Building, Kowloon, Hong Kong (e-mail: [email protected]) 1
2
3
Treloar A, Philpot M, Beats B. Concealing medicine in patients’ food. Lancet 2001; 357: 62–64. Part IVC (Medical and dental treatment) Mental Health Ordinance (Chap 136). www.justice.gov.hk/blis.nsf/ (accessed March 14, 2001). R v Bournewood Community and Mental Health NHS Trust, ex parte L [1998] 3 AU England Reports 289 (HL).
Health system in Yugoslavia Sir—Entering a new era of democracy, the Yugoslavs are faced with operational difficulties and the need to restructure their whole health system. Until the 1990s the National Health Service in Yugoslavia covered, through local and regional taxation, the costs of healthcare. Access to medical specialists was easy and free, and referral rates were higher than in the UK. Hostilities and wars have, however, led to crisis. The UN sanctions, introduced in 1992–93, adversely affected the functioning of the health service1 and the national economy, and led to the influx of around 700 000, mostly Serb, refugees. Drugs and medical equipment could have been exempt from sanctions. However, the approval process was lengthy and required a consensus of all 15 members of the UN Security Council. Therefore, an acute shortage of drugs and medical equipment arose. The ban of all export-import transactions caused the economy to collapse, led to a high unemployment rate (27–49%), a striking decline in the standard of living, and the decrease of the average salary. The decline of the national income resulted also in cuts to the health budget. The shortage of drugs in state hospitals and pharmacies—in which drugs were provided free of charge— forced the population to purchase them in the private pharmacies that had started to open. Many patients could not afford the necessary drugs. Consequently, the rate of death from treatable diseases such as tuberculosis2 and infant mortality3 increased. The
number of patients rose by 7% because of the influx of refugees, which increased the need for medical aid and care. Despite these difficulties, Yugoslav doctors have worked hard. Liver and heart transplantations have been done since 1995; of 15 patients who underwent liver transplantation, 12 have survived for more than 2 years, which is comparable with western European standards.4 More liver transplants are, of course, needed in a population of more than 10 million, but, shortage of funds limits availability. When the sanctions were partly abolished in 1995, drug and equipment purchases became possible. However, the economic situation remained grave and funding and functioning of the health system remained a serious difficulty. Operational difficulties of the health system are especially notable in Serbia, which had to face further war and sanctions in 1998 imposed by the North Atlanatic Treaty Organisation. Health facilities were affected, some were even destroyed through bombing. The bombing of chemical-industry installations around Belgrade released toxic substances into the air,5 and longterm effects of such a pollution remain to be seen. Now, after the victory of its Democratic Opposition, Serbia (and Yugoslavia) is faced with reform, which is already underway. The large hospital services need to be reorganised and restructured to modernise their management. The financial participation of patients in the costs of healthcare services provided is expected to be introduced at the specialist level; therefore, more patients will probably be treated by family physicians. The Ministry for Health is to stop remuneration of hospital-board members and to cut the number of newly admitted medical students. Above all, however, hospitals need almost everything: drugs, diagnostic kits, new equipment, food, sheets, all those items that are indispensable for normal functioning. Slobodan Kazic Zvezdara Hospital, Dimitrija Tucovica 161, 11000 Belgrade, Yugoslavia (e-mail: [email protected]. ac.yu) 1 2
3 4 5
Black ME. Collapsing health care in Serbia and Montenegro. BMJ 1993; 307: 1135–37. Gledovic Z, Jovanovic M, Pekmezovic T. Tuberculosis trends in Central Serbia in the period 1956–1996. Int J Tuberc Lung Dis 2000; 4: 32–35. Litvinjenko S. Migration and health. Srp Arh Celok Lek 1997; 125: 191–96. European Transplant Register, 2000 (www.eltr.org/results). Ashford MW, Gottstein U. The impact on civilians of the bombing of Kosovo and Serbia. Med Confl Surviv 2000; 16: 267–80.
1369
For personal use. Only reproduce with permission from The Lancet Publishing Group.