在联合危机计划的随机对照试验中，严重精神疾病患者知情后预先拒绝治疗：需求、内容和相关性。
Informed, advance refusals of treatment by people with severe mental illness in a randomised controlled trial of joint crisis plans: demand, content and correlates.
机构信息
Health Service and Population Research Department, David Goldberg Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, De Crespigny Park, London, SE5 8AF, UK.
Medical Statistics Unit, Health and Social Care Research, King's College London, London, UK.
出版信息
BMC Psychiatry. 2017 Nov 24;17(1):376. doi: 10.1186/s12888-017-1542-5.
BACKGROUND
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. 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.
METHODS
To 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.
RESULTS
Ninety-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.
CONCLUSIONS
We 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 REGISTRATION
ISRCTN11501328 Registered 13th March 2008.
背景
在英国，精神卫生保健的危机规划应承认根据 2005 年《精神能力法案》做出明智的预先拒绝治疗的权利。我们的目的是在近期因精神病或双相情感障碍住院的服务使用者样本中估计这种治疗拒绝的需求，并检查拒绝与服务使用者特征之间的关系。
方法
为了识别拒绝，我们对联合危机计划进行了内容分析，这些计划是由服务使用者及其临床团队与外部协调员共同制定的，并对英格兰多中心联合危机计划（联合常规心理健康护理）与常规护理单独对照试验（CRIMSON）的亚样本中的常规护理计划进行了分析。使用通过服务使用者和临床医生的基线访谈收集的试验数据以及常规临床数据的收集，确定了与拒绝相关的假设因素。
结果
在 221 份联合危机计划中有 99 份（45%）包含治疗拒绝，而在 424 份基线常规护理计划中有 10 份（2.4%）。没有联合危机计划记录临床医生不同意拒绝。在完成联合危机计划的人中，调整后的分析表明，治疗拒绝与基线时的感知强制之间存在显著关联（优势比=1.21，95%可信区间 1.02-1.43），但与基线工作联盟或既往非自愿入院史无关。
结论
我们证明了根据 2005 年《精神能力法案》书面治疗拒绝的需求显著，而这一需求以前并没有通过治疗计划的制定过程来激发。未来的治疗/危机计划应在起草此类计划时为服务使用者提供记录治疗拒绝的机会。
试验注册
ISRCTN65322433 于 2008 年 3 月 13 日注册。
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