- Case Study Vignettes – Confidentiality and Consent
- Case Study vignettes – Confidentiality
- Anger Management
- Case Study vignettes – the duty and boundaries of care
- Case study vignettes – Nurse Holding Powers
- A Baby Vignette
- Case Study vignette – Blood tests
- Case Study vignette – Complicated Concordance
- Quick mini-scenario
- Case Study Vignettes: Cigarette Rationing
- Case Study Vignette – Just for Socrates
- Case Study Vignette – Anorexia and Veganism
I thought I ‘d trial a new idea on the MN site based on the precept that several student (and pre-student) nurses visit this site. I’ll open up a forum discussion for feedback on the idea in general but leave this thread for responses to the vignette.
The idea is to set a scenario and debate the issues it throws up – I explicitly invite “service users” to also jump in and stir the ethical stew-pot as well as our regular contributors.
#1 is around confidentiality (and risk).
Joe was diagnosed with schizophrenia secondary to drug use some 4 years ago. He’s been in hospital voluntarily on 3 brief occasions (4 – 8 weeks) – once as a social issue when he lost his flat and decompensated; twice for breakthrough symptom management that resulted in medication changes. Currently he’s on Olanzapine 10mg nocte and Risperdal Consta 25mg every 2 weeks. He sees the psychiatrist at outpatients every 3 months and the CPN fortnightly. His next psychiatrist appointment is in 5 weeks.
He has a history of criminal behaviour relating to his drug use (several ‘possessions’ and break & enter convictions) but nothing indicating a history of violence towards others. He has no family living near by, has several acquaintances though no close supportive friends but has been assisted by the local advocacy services on previous occasions. He is currently unemployed and receives DLA and also irregularly attends a day centre facility about two or three times a week.
As a community mental health nurse you visit with him at his home for regular review when he reports an increase in the presence of positive symptoms of schizophrenia. He discloses “voices” that have been telling them to “put the world right again” and thoughts of being “the chosen one”.
Your enquiry as to what this means exactly is replied to with ambivalent statements of “You know – just set the record straight; bring some justice”. Joe does not seem anxious or concerned about his current presentation and identifies no specific ‘plan’ to these thoughts.
You suggest Joe might benefit from an earlier psychiatrist review but he insists he doesn’t think it’s necessary. Then he says “I’d rather you didn’t tell the doctor cos he always messes with my medication and I hate that”.
What are the immediate patient considerations?
What decisions does the community nurse have to make?
What evidence is there to support any clinical decisions?
just a small point mr ian – if you really want feedback from service users, it might help if you knocked the jargon on the head so non-clinicians can easily understand what you’re on about without raiding a dictionary/wikipedia! decompensated … breakthrough symptom management … nocte …. i know what they mean but only because my job demands that i spend most days up to my eyes in policies/guidelines/blogs/websites etc, i don’t think i would have known a couple of years ago.
Hmm I just had to look up the definitions becky, though I had a vague idea.Anyway The Shrink wanted to know the band of CPN & actually it’d probably help me knowing this too.But then I’d also need to know what the CPN bandings mean in relation to competencies.I reserve judgement til I have this info !
Feedback appreciated and noted.
As far as the CPN banding goes – perhaps in a fuller analysis (like an inquiry) this is important to who does what – but on the generic level – the effects on the ethics is of lesser significance. Each increasing ‘band’ or level of responsibility simply builds on the other; so a band-6 nursing response would be of the same origins as a band-7.
I suggest the broad based questions considered in this fashion are suitable to a variety of levels – and indeed other professions.
Oh Mr Ian, I don’t love you anymore – I’m a patient not a service user… I’m not sure how the responsibilities divide between nurses and docs. Personally, I’d go running straight to the Consultant with the information (after looking for signs of cannabise use). Don’t worry about jargon, most of us have decades of experience and know our HCR20′s from our MMSE’s.
Ok I’d like to find out possible triggers for possitive symptoms before trudging to Consultant. Is he abusing drugs ( as per Socrates answer).He might not have been a risk to others in the past, is he now? What of risk to himself ? How long has he been on the Olanzapine (is he still taking it ?)& Risperdal Consta ? Is he still socialising at day centre ? Does he present with Paranoia/past history ? Does he feel safe when in his flat/mixing with people? Do the voices tell him to do anything else & how are they broadcast ?
What Sis said
I would be interested in the CPN band assaigned to him purely because to me this would indicate how complex his case was considered…but I agree it probably isn’t essential.
Just some vague meanderings…As well as considering what Sis already has, I would definately be increasing my visits to monitor him more closely. I’m not sure whether I would go straight to the consultant (given his express wishes that I don’t), depends a huge amount on the answers to the above questions, but the things he’s voicing at present are pretty common and fairly vague. If he got more specific or appeared more agitated when discussing them I would definitely be talking to the doc. Of course, I’d have to tell him we were worried and that we might have to involve the doc, and hope that he didn’t then clam up completely. I would hope I’d have worked with him previously to put together a plan for relapse management, of course this wouldn’t be much good if I was unable to help him see he was relapsing.
My head hurts! I hate case studies. I find them interesting and helpful but always end up confusing myself….
We’ve qualified mental health nurses in the community from band 5 to band 8, with band 3 support workers doing a lot of the important work too. I raised banding simply ’cause what our Trust expects and allows a band 5 to do is different from a Nurse Consultant at band 8.
But I absolutely agree with Mr Ian that this shouldn’t distract from the key themes he asks us to ponder of :
- What are the immediate patient considerations?
- What decisions does the community nurse have to make?
- What evidence is there to support any clinical decisions?
I wasn’t so sure of the current UK “band” situation so apologies if I’m behind the game – used to just be generic CPN (G grade) when I was a lad.
One of the things I’ve also not liked about vignettes is the closed nature of the situation presented – ie so many unanswered questions. So, as “creator” of the Joe character – I’ll answer the raised ones as part of your assessment:
He’s considered to require simplex maintenance treatment and is assigned a lower level (?band) CPN. You’ve known him for about 6 months and this is the first time you’ve been noted any significant change in his presentation. He was last in hospital 8 months ago when he was changed to the Risperdal Consta.
He denies any recent increase in illicit drug use.
He’s been on 10mg Olanzapine for 2 months, since his last psychiatrist review and states he is still taking it – and also states he has on occasion taken an extra one “when the voices are bad” during the day – as written on his relapse management plan. His Relapse Plan also states he should go and see the psychiatrist when he gets these symptoms.
He says he still goes to the day centre.
His in-patient past history indicates incidences of being guarded about his thoughts and a few ‘?paranoid’ events such as declining meals; watching others intently and infrequently not accepting his medications – and he has refused to engage with certain other therapists on times, stating he doesn’t trust them.
He states he feels completely safe with himself (and has no history of attempted suicide – though has been psychotoxic from amphetamine over-use in the past).
He says the voices are from God and sometimes He sends messages through the local TV news to him.
During the course of this assessment Joe remains calm and does not appear bothered by your questioning.
Your 45 minute assessment time is now up ….
I didn’t realise a nurse would be in a position to give an undertaking NOT to pass on information to the man’s doctor… Could somebody expand on this?
Ah, this sounds somewhat like what we patients term “smoking room drama”.
Another patient gets friendly with you and decides to tell you their life story, including a particularly upsetting case of sexual assault when they were 7. You venture, ‘um, you have told the consultant / the nurses about this already right?’. ‘No, I don’t trust them’. (You end up developing these very intense friendships very quickly in hospital).
My action whenever something like this happened was to go straight to a sympathetic member of staff and tell them what had transpired. And explain to the person in question that it wasn’t fair to expect me to keep something like that quiet. (There was one exception, a woman who told me she was going to kill herself when she was discharged and I didn’t tell anyone. Yes, she tried but someone found her in time. In my defence, I was so nuts at the time that by the time she was readmitted, I was in the IPCU).
I think to be honest that the reason someone tells another patient something like that is that they want the doctor to know, but aren’t able to do it themselves.
Mind you, that’s completely different from what a nurse would/should do as the motivation for telling a CPN something might be completely different.
The trick is to stay away from the smoking room btw. Harsh, but getting involved in everyone else’s problems does not help you or anyone else really…
Socrates I was reading sbout this last night:-
Code of Practice Mental Act 1983 mentions ‘ordinarily information about a patient should not be disclosed without their consent.Occasionally it may be necessary to pass on paticular information to professionals or others in the public interest, for instance where personal health or safety is at risk’. Also under the Data Protection Act 1998 ‘a local authority may disclose information to staff involved in the case & their line managers on a strictly need to know basis’.
Personally I’d be inclined to follow his Relapse Plan & try encourage him to see Psychiatrist sooner paticularly, if things get worse in, that he is a threat to himself or others or he feels unsafe.If he says no then would argue Duty Of Care position of CPN.I stress though only if things go downhill.Give it a day or two & contact him to see how he is with proviso of a further assessment by CPN.
Mind you if I was a relative/friend I’d march him to the Psychiatrist, because I do overreact !
In simplified terms Socrates – a nurse is bound by the Code of Conduct of the NMC first and foremost. This Code (recently changed: May 2008) holds the patient’s interests above all others.
http://www.nmc-uk.org/aArticle.aspx?ArticleID=3056
Other considerations are (in hierarchy – I think):
Legal responsibilities (which over-rides Code of Conduct) – such as disclosures on criminal activity or threats of harm to others.
Inter-professional liaison – as is required by the NMC Code to “work with others”.
Organisational requirements – such as any NHS policies.
I’d breach an organisational policy if it conflicted with an NMC Code; but I would breach NMC Code if it conflicted with Law (as the Code directs me to).
eg 1. If the service targets says only one hour per consultation with a patient – I’d still give them the time I felt they needed, as the NMC would expect this for the patient, and I would not follow the organisational requirement – but then I’d raise the general issue at next planning meeting
eg 2. Patient states they don’t want their evening medication but can I pretend they had it so they don’t get into trouble with the doc or other nurses? The law requires a nurse to accurately record medication administration – so, no, I can’t pretend. And it’s professional collaboration to pass on such information. I wouldn’t necessarily administer – even tho the doctor’s prescription says it should be given – and the MHA law empowers me to enforce it (unless it was unavoidably necessary for the benefit of the patient or others at risk) – I would assess the patient’s best interests first.
However, in the case of ‘not informing the psychiatrist’ – it’s more about “how” the psychiatrist is informed of “what” and “when”. c_d mentioned not going straight to the psychiatrist – this is not saying you won’t make the information available – it’s saying you won’t jump to get the psychiatrist to intervene but you will seek a more amenable approach concordant to the patient’s expressed desire.
)
Our beloved Shrink(s) might like to think he has us nurses at beck and call – but we play a double-agent game with the psychiatrists (shhh!
[The 'trick' is to realise it's not the psychiatrist the patient dislikes - it is the potential for more medication changes - and thus some compromise might be reached with the patient in this area - now stop making me give answers away!
].
Woah! Mini-Essays… Will spend a couple of hours digesting and report back…
Not read any other replies, so forgive me if I’m repeating things here. The nurse’s responsibility here is clear – the patient should be aware that the CPN will not keep secrets for him, and if he isn’t then the CPN hasn’t set the boundaries of their relationship terribly well. Any evidence of deterioration needs to be shared with the team, end of story.
I read this and thought it was overburdened with medical speak
I would have thought the CPM would have like beakie said set boundaries when first starting to care for Joe – Despite what the public likes to think Doctors aren’t in charge of Nurses and Nurses are not duty bound to tell Docs everything UNLESS not telling the Doc something would actually harm the patient/others and also (probably) it was in the Docs power to do something about it. I would hope that if the CPN felt he had to tell the Psychiatrist anything he will tell Je first and also tell him why he is telling the Doc. I would think the CPN should perhaps arrange to be in touch with Joe a bit more – I would take it as read that he/she would check things like meds/street drug use etc as well.
Re the secret agent comment from Mr Ian – I would like to think Docs/Nurses/PAMs all respected each other and did not play games with each other.
Re the secret agent comment from Mr Ian – I would like to think Docs/Nurses/PAMs all respected each other and did not play games with each other
The comment was extremely tongue in cheek. Perhaps the wrong place to continue the nurse/medic banter in this thread? Apologies.
Not read any other replies, so forgive me if I’m repeating things here. The nurse’s responsibility here is clear
I’m very disappointed, And you’re so very wrong. You have placed the nurse-psychiatrist relationship above the nurse-patient relationship.
I was about to chip back in, but as the temperature is rising, I think I’ll leave it to the professionals. *DUCKS*
I would hope that if the CPN felt he had to tell the Psychiatrist anything he will tell Je first and also tell him why he is telling the Doc
This is indeed a good approach to have. Seeking to negotiate with the patient and discuss the issues honestly is paramount. There are times where risk to self or others outweighs any obligation to the patient – is this one of them?
However, in seeking an ethically satisfying outcome to the dilemma, I’ll reiterate a component of the scenario that hasn’t been commented on as yet:
He has no family living near by, has several acquaintances though no close supportive friends but has been assisted by the local advocacy services on previous occasions
Then he says “I’d rather you didn’t tell the doctor cos he always messes with my medication and I hate that”.
He’s just specifically told you why he doesn’t want the doctor to be told, and furthermore something that suggests he’s feeling pretty pessimistic about the extent to which the doctors can/will help him. Now, I might be projecting my own “dammit, the shrinks never listen to what I say” issues here, but why not start by discussing that with him?
You have placed the nurse-psychiatrist relationship above the nurse-patient relationship.
Nope. I have placed the safety of the patient and others first. He is clearly becoming unwell again. Keeping this a secret from the rest of the team may well make the nurse feel better about her “relationship” with Joe, but it helps nobody else, least of all Joe. How long is she going to let him go on deteriorating before she takes action?
I’ve seen “the therapeutic relationship” used as an excuse for doing bugger all in the past, and it sucks (to quote a current housemate in Big Brother)
In the grand scheme beakie – you’re probably 90% or more right to presume the final outcome of reporting. I’m a little disappointed you’d jump to it tho and not have a better process than simply “Any evidence of deterioration needs to be shared with the team, end of story” that precludes the other potential times it might not be necessary – and that it’s simply about you and the doctor’s needs.
There is no clear indication safety is a paramount issue here altho risk will have increased.
What of negotiating an intervention with the client?
What of including the advocacy services he has previously used?
What of reviewing with peers or line managers in clinical supervision?
What of discussing with him the medication issues before you represent “Joe’s deteriorating” to the doc?
What of seeking to empower the patient to determine care for themselves?
Looking at alternative methods or agreements (eg I note Relapse/Crisis Plan was mentioned)?
You are advocating simply escalating the issue to the consultant and moving on to the next one?
And boundary issues – so the patient once aware – always agrees? Cannot withdraw that consent (yes – it is consent – unless you can provide clinical defensible reasons for breaching a patient’s confidence – everything is under consent)? Is he not to be afforded confidentiality in any regard – and is this because he has a mental illness and you have blanket assessed he can’t determine for himself? Is he not to have his concerns considered in your interventions until after you have satisfied your inter-discipline and organisational needs?
This is simply contrary to the primary ethos of the NMC Code.
Are nurses seriously being taught to simply monitor and report still?
That’s very 80′s and very scary considering the rhetoric I read on “patient centered” nursing.
and that it’s simply about you and the doctor’s needs
This is you placing your own interpretation on what I said, in complete denial of the fact that my primary concern would be the patient’s wellbeing.
And your noodling about boundary issues is just navel-gazing. It is crystal clear in the NMC’s various statements about it that confidentiality is not at the level of a priest in the confessional, and that you have a duty to work collaboratively with other professionals in your team. You cannot share information with Mrs Joanna Public on the bus home, but you are expected to share information with the team you are employed with.
You are advocating simply escalating the issue to the consultant
I said “the team”. For discussion. You know – interprofessional working and all that.
I could right an essay on this but I’ll just try and keep briefly to a few bullet points. This means there’s a paucity of explanation and it’s incomplete.
What are the immediate patient considerations?
Is Joe mentally unwell (it would seem yes)
Is his mental health getting worse (it would seem yes)
Is his mental health impacting adversely upon him or property or others (it would seem yes, to a degree, affecting his wellbeing)
Is there any reason evnident to account for the deterioration (psychosocial adversity, change of dealer, escalating self-medication with street drugs)
Joe needs to be made aware that the CPN doesn’t have her own personal medical notes for Joe, all documentation’s available for the whole team to see. Whilst being sensitive to not needlessly disclosing personal dialogue, Joe should know that the CPN works in a team and has to generate accurate contemporaneous clinical records that other team members will be able to see.
What decisions does the community nurse have to make?
Is Joe a capacitated adult with respect to treatment decisions, within the meaning of the Mental Capacity Act 2005 (this hasn’t been established with the info we’ve been given)
From this, is Joe able to generate valid treatment plans collaboratively with the mental health team?
Why a lone worker, would it be better for the psychiatrist to be seeing Joe in the community too, with the CPN?
Why is Joe on oral olanzapine and depot risperidone and is this justified?
Then an easy but important decision : What support should be offered to Joe?
What risk assessment (Sainsburys etc) needs to be undertaken in accordance with the Trust’s clinical governance arrangements and Lone Worker policy?
What evidence is there to support any clinical decisions?
Deterioration of schizophrenia with substance misuse and impact of this and escalating symptoms evidence unmet clinical need that warrants support.
Risks to self, property or others wouldn’t at present seem to be high. Hospital in-patient care isn’t necessary.
He’s still engaged with the mental health team.
Given that in the NHS we work in teams there are no patient rights to specific workers or professional groups (eg a patient doesn’t have a right to always only see Debbie the band 6 CPN, or always only see Claire the Consultant Psychiatrist or always only see Sam the CBT therapist). Professionals may change (it may be a different CPN doing the risperidone depot when Debbie’s away) or professions may change (review may be by a CPN, psychiatrists, social worker or OT). Information has to sensibly be shared by the team and even before clinical supervision it’d be common for a team to discuss who’d been seen and if anyone’s health has deteriorated when we’re all in the CMHT at the end of the day. At least there’s multidiscimplinary input into every patient’s care that way, with medics and social work and nursing and OT being able to muse over who’s been seen and how folk can be helped. Also, discussion may make it clearer as to why oral olanzapine and depot risperidone’s being used.
Other issues of concordance with medication, psychopathology, surveillance, MHA 1983, criminality, positive risk taking, advocacy and IMCAs, the irregularity of day centre attendance, polypharmacy, possibility of treatment resistance, role of dual diagnosis services, physical morbidity and ADLs/what he’s doing through the week I’ll leave to others
beakie I’m just bloody annoyed at you for your off the cuff answering and I’m going to put gum in your hair.
I still think you are presuming being justified in your decisions based on clinical opinion (which you might think you are entitled to do at your level of expertise – and perhaps should be) – but you’ve avoided explaining and evidencing your answer (which kind of shits me for the role you are in).
I’ll write another one this weekend for you to show how clever you are.
Shrink:
Why is Joe on oral olanzapine and depot risperidone and is this justified?
Ask the psychiatrist! I’ve noted more frequently (locally) the use of two atypicals of late which used to be against current advice. It wasn’t actually an itended part of the scenario – but thanks for picking up on it as it would perhaps be of consideration as to why the patient was adverse to the psychiatrists interventions with his medications.
I also note amidst your expansive answer you’ve omitted to directly identify the patient adversity to the potential medication changes and how to address this.
This is the crux of the ethical dilemma – how do you do what you have to do professionally (ie share and report concerns) whilst supporting the patient’s expressed desire – not to want medication changes – anyone know why not?
but you’ve avoided explaining and evidencing your answer
I’m sorry, I wasn’t aware I was submitting a paper, I thought I was just expressing an opinion.
Opinion: (thanks Beakie)
Tell the team.
The how and when are up for debate and discussion and will depend on the relationship between the nurse and client. As well as what is known of Joe’s history. For all we know Joe has a habit of settings things right by sending long and rambling letters to the local free paper. In which case slightly more intensive monitoring might be best and waiting to report back at the next team meeting.
The more Joe is involved in this process the better. Hopefully a solution could be reached where Joe does the telling.
No evidence base unless you are going to give me CAT points.
ok well I had a slightly different idea on how to proceed to most rather than just report to the team.
I note a general pervasion of ‘better safe than sorry’ – but this seems to be in terms of the managing the illness; preserving the integrity of the service and not much on supporting the person.
1. What are the immediate patient considerations?
In terms of confidentiality – Joe has expressed he doesn’t want you to disclose to the doctor his issues.
His concerns is not to have his medication messed with again. It would be relevant for the nurse to consider this and try to unravel what it is exactly Joe dislikes -
- going into hospital again?
- having to be a guinea pig for some weeks?
- knowing he will potentially get worse than better?
- perhaps he actually finds this medication helpful but is having a rough time just now – maybe he wants to ride it out and see if he comes good again?
Following this, it is necessary to discuss with the patient your intentions. Where possible, it is preferable to let Joe realise the protocols that need to be followed – and work with him to develop a plan on how this is achieved.
eg That he needs to be reviewed – there are options on how this can be achieved and it certainly doesn’t always involve a hospital admission.
This approach will minimise how disempowered Joe might feel through this event.
When an issue presents itself such as this – gather the collateral and information that allows you to make the best decisions and discuss them with the patient.
Use your assessment skills to pin point the issue(s) as best you can. Knowing the issue will also make you more able to vision a mutually agreeable resolution so you can support the patient to manage the event without compromising the relationship.
2. What decisions does the community nurse have to make?
Joe has displayed some insight/awareness into his increasing symptoms and this is perhaps worth working with in terms of psychological interventions and increased general support.
http://focus.psychiatryonline......ct/6/2/257
The breakthrough of symptoms indicates an increased risk of repeating previous behaviour whilst unwell. However, Joe’s previous behaviour does not include history of any significant risks to self or others.
The nurse should discuss with Joe these concerns and establish his intentions, if any, more clearly. It would also be useful to test out his ability to apply moral reasoning – even if the voices tell him to do something aberrant, how likely is he to follow through?
The nurse who has the collateral can present the issues to the team and also can possibly suggest any interventions or ‘tweaks’ to the current support provisions that may have already been discussed with Joe.
In regards the sharing of information – if the patient expresses not to disclose there is a requirement that the nurse employs the best pathway to ensure the patient does not feel deceived.
Discussing the issue openly allows for the patient to be aware of the concerns the nurse has. The nurse should reiterate her obligations to the whole process of care and establish an understanding with Joe that any reporting back is not for the purpose of merely changing his medication but to provide optimum care through communication.
In this scenario it would perhaps be beneficial to encourage Joe to engage his local advocacy services. This not only preserves Joe’s individual right to representation, but also allows the nurse to demonstrate consideration for Joe’s expressed desire that he has concerns about treatment changes without compromising her position.
In order to provide significant collateral, it would be also worth considering requesting Joe to give a urine sample for drug screen.
3. What evidence is there to support any clinical decisions?
There is an implied risk to others through the command hallucinations.
In the context of this scenario the lack of historical evidence of violence risk is a strong support for not ‘over reacting’ other considerations in the assessment should include:
physical agitation and/or anger
expressed intent to kill or take revenge
identification of specific victim(s)
psychotic symptoms, especially 2nd person command hallucinations to commit violence
persecutory delusions
disinhibition caused by traumatic brain injuries and other central nervous system dysfunctions
current use of alcohol or other drug
http://priory.com/psych/risk.htm
The outcome of the drug screen will further inform your probability of risk. Positive testing for illicit substances indicates an increased risk of violence or aggression (by x3 – tho there are no specifics on whether type of drug makes a difference) as does presence of a mental illness. However, the absence of history slightly ‘dampens’ the risk.
http://www.psychology.org.au/p.....sych/risk/
All this information directly relates to the ‘relevance’ and ‘urgency’ of the event. The relevance is in terms of what the information indicates and is used to determine whether to escalate interventions. The urgency is what is used in determining how quickly to escalate.
Indeed, relevance is what determines whether we breach confidence – and urgency might determine to whom and how quickly.
In relation to this case, I would suggest the relevance is significant – but the urgency is moderate to low.
Coming back to the party waaaaaay late, but… this is really the kind of thing that should be discussed with the patient at the start of treatment. What things can be kept confidential, and what things can’t. I just got a new counsellor, and before we started talking about my craziness, we had the “everything is kept confidential apart from X, Y and Z, which we have to disclose” conversation. Mental health treatment already feels, half the time, like a game where nobody tells you the rules. So tell the patient the rules.
This is certainly how the real world views it but..
When the “rules” are laid out – the patient consents to them by continuing but remains free to withdraw consent at any time.
Stating I don’t wish this to be disclosed is withdrawing consent.
The patient is voluntary and the rules go both ways.
No, the patient does not have to consent to every disclosure or else the whole health care system would fall down within days. The patient’s consent is implicit in them continuing to talk to you despite you having informed them of the boundaries of confidentiality.
“No, the patient does not have to consent to every disclosure”
Of course not – at least not formally (did I, or someone else, imply that?) – all consent remains until such time as it is withdrawn.
If the patient determines to not want to have information passed on then the nurse advises of their obligations to the team as well as the patient (both as advocate and treating team member) and, where applicable, the law.
The patient can, at anytime, enforce their right to confidentiality by choosing not to disclose – but this creates something of a therapeutic impasse.
Does this imply that the nurse-team relationship is of greater importance then the nurse-patient one? (I’ll answer myself)
In considering the general beneficence to the patient the nurse has to weigh the gravity and significance of the information – eg safety – and the reasoning of the patient – eg if paranoid then this is a component of the illness that impairs decisions.
It’s down to splitting hairs now. Only the truly pedantic (like myself – see below!) should continue
)
Does any disclosure automatically become the “right” of the ‘team member’ as part of the therapeutic relationship?
How would this work in a private nurse-counsellor practice?
I guess it would be an interesting legal concept to determine who actually “owns” the information once imparted?
It would also be useful to do the ‘front page’ test – ie “If I do this – what headlines might the news put on it if it goes tits up?” – vis “Negligence”
If there is an element of risk to the patient or others, you are obliged by the Code of Conduct to disclose.
A precedent was set, I seem to remember, by a case in California wherein a student disclosed to a counsellor that he wanted to kill girl A. He subsequently went on to kill girl A. The counsellor had not disclosed the information to girl A, to the campus police or to the parents of girl A. The determination was that he should have done so. I may have some of the details cock-eyed, but that’s the nub of it.
I’m similarly aware of some such story. There’s a clear indication of risk tho when someone says “I’m going to kill girl A” as opposed to “voices” that have been telling them to “put the world right again” and thoughts of being “the chosen one”.
There is an indication of concern – due to existence of what might be considered command hallucinations – tho the object behaviour and potential victims are not clearly identifiable – just cos he doesn’t disclose a plan, doesn’t mean he hasn’t got one, right?
This leaves the matter wide open for speculation. To err on the side of caution is the popularist view – but then are we succumbing to and measuring by the same stigmatism and stereotyping that we dislike so much?
“An element of risk” – by nature of having a mental illness, some would say there is an element of risk even before the disclosures.
As a comparative experience – I had a patient with history of fabricating disclose to me once that some guy he knew had asked him that evening on the phone to ‘take out’ “a girl” [he named the girl - and the 'friend' he'd spoken to]. I asked him to clarify ‘take out’ (well I said – “That’s nice, where are you thinking of taking her?”) – and he said “Ya know – [points fingers and closes one eye to take aim] …. that sorta take out”. Oh ok.
I wasn’t too concerned at that moment as he was a patient in the secure mental health and it was evening time – but, he then escalated the story – “Yeah I told him I couldn’t – so he said he was going to do it”.
It was 98% guaranteed fabrication but I still called the police.
I’m still concerned that no-one seems to advocate engaging Joe in conversation as to a) exactly what he means and b) exactly why he doesn’t want to discuss it with the doctor. It seems to me that everything else is contingent on these two things. You’ve said he’s mad; you haven’t said he’s stupid or mute. So talk with Joe.
Also, Mr Ian, from my point of view as an extremely reluctant service user, the whole confidentiality/disclosure thing remains pretty simple. I expect to be told in advance if there’s something that can’t be kept confidential, and I expect everything except that to be respected. Sudden wavering around these boundaries is the kind of thing that makes me drop out of treatment because I’m sick of being messed around.
[...] shift as nurse in charge of the acute mental health unit to be informed of a new admission. Joe (from previous vignette), was reviewed by the community consultant psychiatrist and admitted voluntarily on Friday [...]