In 2003, National Institute for Health and Clinical Excellence (NICE) recommended that, ‘The choice of drugs prescribed in acute mania should be made jointly by the individual and the clinician(s) responsible for treatment. [It] should be based on an informed discussion of the relative benefits and side-effect profiles of each drug, and should take into account the needs of the individual and the particular clinical situation. In all situations where informed discussion is not possible, advance directives should be taken fully into account and the individual's advocate and/or carer should be consulted when appropriate’ (NICE, 2003).
We completed an audit cycle to examine the compliance with this recommendation. After discussion with the clinicians locally, it was agreed that any documentation indicative of a discussion on drug selection between the clinician and the patient or his/her advocate/carer, or reference to the advance directives, will be accepted as the standard.
The first phase of the audit cycle was conducted in 2004. The in-patient notes of the adult patients admitted with acute mania were searched for the above information or documentation of capacity assessment.
The results and the recommendations from the first cycle were presented at the local educational meeting and a report was submitted to the trust audit department to be circulated to all the clinicians and made available on the intranet. The re-audit was conducted in 2006.
In 2004, out of a total of 38 case notes examined, only 13% had any documentation towards joint decision on drug selection. In 2006, 32 case notes were examined and 40% of these had joint decision documentation. None of the case notes (in 2004 and 2006) had any reference of capacity to consent, advanced directives or discussion with carers.
It is possible that the joint discussions on the selection of drugs are held but not documented for various reasons, for example lack of time or ignorance. The patients might lack capacity due to severity of their illness and the relative or carer might not be available to give consent. In both phases of audit cycle, more than half of the patients (55% in 2004 and 66% in 2006) were detained under the Mental Health Act 1983 and about a third (29% in 2004 and 37% in 2006) required admission to the psychiatric intensive care unit reflecting the severity of illness. Nevertheless, the Mental Health Act code of practice clearly indicates that a detained individual is not necessarily incapable of giving consent and the interview at which their consent for treatment was sought as well as assessments of their capacity should be fully documented in the patient's notes.
It will be interesting to hear views and experiences of other clinicians in this area.
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