Feiring Eli, Ugstad Kristian N
Department of Health Management and Health Economics, University of Oslo, Blindern, Oslo 0317, Norway.
BMC Health Serv Res. 2014 Oct 25;14:500. doi: 10.1186/s12913-014-0500-x.
The use of involuntary admission in psychiatry may be necessary to enable treatment and prevent harm, yet remains controversial. Mental health laws in high-income countries typically permit coercive treatment of persons with mental disorders to restore health or prevent future harm. Criteria intended to regulate practice leave scope for discretion. The values and beliefs of staff may become a determinating factor for decisions. Previous research has only to a limited degree addressed how legal criteria for involuntary psychiatric admission are interpreted by clinical decision-makers. We examined clinicians' interpretations of criteria for involuntary admission under the Norwegian Mental Health Care Act. This act applies a status approach, whereby involuntary admission can be used at the presence of mental disorder and need for treatment or perceived risk to the patient or others. Further, best interest assessments carry a large justificatory burden and open for a range of extra-legislative factors to be considered.
Deductive thematic analysis was used. Three ideal types of attitudes-to-coercion were developed, denoted paternalistic, deliberative and interpretive. Semi-structured, in-depth interviews with 10 Norwegian clinicians with experience from admissions to psychiatric care were carried out. Data was fit into the preconceived analytical frame. We hypothesised that the data would mirror the recent shift from paternalism towards a more human rights focused approach in modern mental health care.
The paternalistic perspective was, however, clearly expressed in the data. Involuntary admission was considered to be in the patient's best interest, and patients suffering from serious mental disorder were assumed to lack decision-making capacity. In addition to assessment of need, outcome effectiveness and risk of harm, extra-legislative factors such as patients' functioning, experience, resistance, networks, and follow-up options were told to influence decisions. Variation in how these multiple factors were taken into consideration was found. Some of the participants' statements could be attributed to the deliberative perspective, most of which concerned participants' beliefs about an ideal decision-making situation.
Our data suggest how a deliberative-oriented ideal of reasoning about legal criteria for involuntary admission lapses into paternalism in clinical decision-making. Supplementary professional guidelines should be developed.
在精神病学中，非自愿住院对于实施治疗和防止伤害可能是必要的，但仍存在争议。高收入国家的精神卫生法律通常允许对精神障碍患者进行强制治疗，以恢复健康或防止未来的伤害。旨在规范实践的标准留有自由裁量的空间。工作人员的价值观和信念可能成为决策的决定性因素。以往的研究在很大程度上仅探讨了临床决策者如何解释非自愿精神病住院的法律标准。我们研究了临床医生对挪威《精神卫生保健法》中非自愿住院标准的解释。该法案采用了一种状态方法，即只要存在精神障碍且有治疗需求或患者或他人存在可感知的风险，就可以使用非自愿住院。此外，最佳利益评估承担着很大的正当性负担，并允许考虑一系列立法外因素。
采用演绎主题分析法。构建了三种理想类型的强制态度，分别称为家长式、审议式和解释式。对10名有精神病护理住院经验的挪威临床医生进行了半结构化的深入访谈。数据被纳入预先设定的分析框架。我们假设数据将反映现代精神卫生保健中从家长式作风向更注重人权方法的近期转变。
然而，数据中明确表达了家长式观点。非自愿住院被认为符合患者的最佳利益，患有严重精神障碍的患者被假定缺乏决策能力。除了评估需求、结果有效性和伤害风险外，患者的功能、经历、抵触情绪、人际关系网络和后续选择等立法外因素也被认为会影响决策。发现了在如何考虑这些多种因素方面存在差异。一些参与者的陈述可归因于审议式观点，其中大多数涉及参与者对理想决策情况的信念。
我们的数据表明，在临床决策中，关于非自愿住院法律标准的以审议为导向的理想推理如何陷入家长式作风。应制定补充性专业指南。
