Ethics & Legal Issues in

Psychiatry

Topics to cover
Ethics
Basic Ethical
Principle
Sexual boundary
violation
Non-sexual
boundary violation
Confidential

Legal Issues

Malpractice
Right of patient
Informed consent
Admission to ward

Basic Principles of Medical

Ethics Description
Principle
Beneficence

Fundamental commitment
of a doctor to provide
benefit to patients and to
balance benefit against
risks when making decision

Non-maleficence

Avoiding harm to a patient

Autonomy

Respect for a patients right

to make his or her choice
Confidentiality

Justice

Fair distribution of
psychiatric services or
resources
Be truthful to the patients
in disclosing informations

Medical Ethics

Summary of Selected Ethical

Principles for Psychiatrists
Principle

Annotations

Competent care

The psychiatrist must scrutinize

the effect of his/her conduct on
the boundaries of the treatment
relationship.

Honest dealing

Information given by patients

should not be exploited.
Contractual agreements should
be explicit (very clearly stated,
not vague, leaving room for
confusion or doubt)
Fee splitting is unethical. (i.e get
paid for referral)

Confidentiality, respecting
colleagues

Restraint in release of information

to third parties.
Adequate disguise of case
presentations.
Confidentiality in nontreatment
situations.

Boundary Crossings and

Violation
Definition of boundary:
the expected and accepted psychological and
social distance between practitioners and
patients with component of transference and
countertransference
Definition of boundary crossings/violation:
The relationship between the physician and the
patient that deviates from basic goal of
treatment which may lead to non-therapeutic
activity (these activity mayb harmful or
harmless)

Boundary Crossings and

Violation
Definition of boundary crossings:
Deviation from classical therapeutic
activity that is harmless, nonexploitative, and possibly
supportive of the therapy itself
Definition of boundary violation:
a boundary violation is harmful or
potentially harmful, to the patient
and the therapist

Slippery Slope Concept

The doctor is responsible for
preserving the boundary
If even a minor violation occurs, it is
better to transfer the patient to a
colleague
The boundary violation typically
starts small and become
incrementally problematic and it will
starts sliding down the slope

Non-sexual Boundary Issues

Spend more time with attractive patient but
less with the unattractive one
Scheduling patient outside regular hours or
extending time beyond what was initially
agreed
Hidden motives in patient (eg. Transference of erotic
and extraordinaryly demanding patient)

Offering more follow ups than medically

necessarily
Place of consultation at other place
If visiting patient dying of cancer, it is acceptable
If in unordinary place should be part of a
management plan

Non- sexual Boundary

Issues
Give excessively drug samples or accept gifts from patient
May be used as a form of incentives so that the treatment will
be under control of the patient
Must be discussed the meaning of the present

Using abusive language (or any other thing other than the
surname, or last name, or name depending on the
situation)
Excessive self-disclosure
Excessive countertransference

Non- sexual physical contact

In sexual trauma patient, a touch and kiss might be offensive
A touch or hug may carry a different meaning to patient that the
intended meaning by physician

Sexual Boundary Violation

Usually begins with relatively minor
boundary violations
A direct shift from talking to
intercourse is quite rare; the
slippery slope is the characteristic
scenario

Therapist Profile in Sexual Boundary

Violation
Psychotic disorders
Patient and physician sexual behaviour that develop
out of frank delusion in mania, schizophrenia and
other psychotic disorder
Small group

Predatory psychopaths and paraphilias

Usually in personality disorder of severe narcissism
and antisocial personality.
Abuses power and thinks they are in upper echelons
with ethics code not applied to them
Some show no remorse to their action
Multiple victims

Therapist Profile in Sexual Boundary

Violation
Lovesickedness
Usually neurotically organized, mild narcissm and In professional
crisis
No history of misconduct or usually in one patient
Typically female
May profess they are 'in love' with patient and patient felt the same
this group include a desperate need to be validated, idealized and
loved by patients as a way of regulating the therapist's self-esteem.
unable to see that something from the patient's and/or the therapist's past is
being repeated in the present

Masochistic surrender
often been highly ethical throughout their careers. They may be regarded as
expert in treating "difficult" or "impossible" patients
. They also may believe that by sacrificing themselves, they are somehow
saving a patient from suicide

Slippery Slope Simons,

1995

Therapists neutrality is eroded in little ways

Therapist and patient address each other by
first names
Therapy sessions become less clinical and more
social
Patient is treated as special or condidant
Therapist self-disclosures occur, usually about
current personal problems, sexual fantasies
about the patient
Therapist begins touching patient, progressing
to hugs and embraces

Slippery Slope Simons,

1995
Therapist gains control over patient, usually by
manipulating the transference (the emotions of a
patients redirected to the therapist) and by negligent
prescribing of medication
Extra-therapeutic contacts occur
Therapy sessions are rescheduled for the end of the day
Therapy sessions become extended in time
Therapist stops billing the patient (in National Health
Service settings this is not relevant)
Therapist and patient have drinks/dinner after sessions;
dating begins
Therapistpatient sexual intimacy begins

Conclusion
It is ALWAYS the therapists
responsibility to know what is
appropriate and never to cross the
line
College of Physicians and Surgeons of Ontario,1991

Confidentiality
Confidentiality is defined as the clinicians
obligation to keep information learned in that
relationship unavailable to third parties
And about whatever I may see or hear in
treatment, or even without treatment, in the
life of human beings- things that should not
ever be blurted out outside- I will remain
silent, holding such things to be unutterable
[ sacred, not to be divulged (make known
private or sensitive information) ]

Circle of confidentiality

Circle of confidentiality
Within the circle, information about
the patient is shared without the
patients consent
Although the patient is inside the
circle, the patient may speak to
anyone outside the circle without
restriction

Exceptions to confidentiality
Patient consents to release of information
Duty to protect (eg. HIV, homicide, dangerous driving)
Emergencies (attempt suicide, drowsiness after
intoxication, critical condition after hanging)
Mandatory reporting statutes (child protection, fitness
to drive, registration board)
Court-ordered evaluations (Balance duty to court and
duty of care to patent)
Patient initiates litigation (an action brought in court
to enforce a particular right. The act or process of bringing
a lawsuit in and of itself; a judicial contest, any dispute)
Incompetent patient/ lack of capacity
Confidentiality in minors

Patients Right

In general..
1) Respectful and safe care given by competent personnel
2) Be informed of patient rights during the admission
process
3) Be informed in advance about care and treatment and
of any change
4) Participate in the development and implementation of a
plan of care and any changes
5) Make informed decisions regarding care and to receive
information necessary to make decisions
6) Refuse treatment and to be informed of the medical
consequences of refusing treatment
7) Personal privacy and confidentiality of medical records

Patients rights under the Mental Health Act

Right 1: The right to information

information about their treatment,
including any likely side effects and
the expected benefits of the
treatment
information about their rights to have
their condition reviewed

Right 2: Respect for cultural identity

Treated with respect for their cultural and
ethnic identity, language and religious or
ethical beliefs
Right 3: The right to treatment
Professional standard treatment that will
benefit the persons condition.
Does not have to cure their condition but
should at least relieve their symptoms or
stop them from becoming more unwell.

Right 4: The right to be informed about treatment

Receive explanation about the

benefits and likely side effects before
treatment given.
The information should be in a form
that they can understand and should
be repeated if necessary.

Right 5: The right to independent psychiatric

advice

If a patient is unhappy with their

diagnosis or treatment they can ask
an independent psychiatrist for a
second opinion.

Right 6: The right to legal advice

A patient has a right to a lawyer to give
them advice about the Mental Health Act
and to represent them at hearings, reviews
and appeals, and to give them advice
If a patient doesnt have a lawyer, staff at
the hospital or a district inspector should
help with finding one.
If a patient cannot afford to pay for a
lawyer they may be eligible for legal aid

Right 7: The right to company

A patient has a general right to the

company of other people.
A patient can only be isolated or put
into seclusion if this is necessary for
their treatment or safety, or for the
protection of others.

Right 8: The right to have visitors and make

telephone calls

This right can be lost if the patients

responsible clinician believes that to
have visitors or make calls would be
detrimental to the patients interests
or treatment.

Malpractice

The failure to exercise a degree of skill that

would be reasonably expected of a doctor in
similar circumstances resulting in harm to the
patient.
It is a noncriminal, noncontract wrong
resulting from a physician's negligence that
causes injury to a patient under his or her care

4 Ds of Malpractice
Duty
Dereliction of duty
Damage
Directly causing

In order for there to be a case for

malpractice, four elements must be
present:
DUTY. There must be a doctor-patient relationship, which
establishes the duty of "reasonable care
Dereliction of duty. The psychiatrist has to breach the
duty of reasonable care. there is negligence if there has been
a breach of duty of reasonable care."
Damage must have occurred. The definition of harm could
include injury such as broken bones or memory loss, but also
includes emotional injury."
Directly causing. A causal link must be demonstrated
between the negligence and the injury Often this fourth
element can be the most difficult to establish. "There may be
cases in which there is duty, and the doctor breaches the duty
and there is harm but it is difficult to prove the harm was caused
by the breach of duty because there may have been other
intervening factors that could also account for the harm.

Common forms of psychiatric negligence

Failure to conduct a propersuicide risk

assessment
Standard of care required it to be done on
every potentially suicidal patient.
If a doctors fails to properly assess the
patient considering all the relevant factors
such as patient history, age, gender, sexual
orientation, employment and living
standards, then he is at risk for potential
litigation.

Failure to prevent a patients suicide

If a proper suicide risk

assessment has been performed
and it has been determined there is a
legitimate risk of suicide, a doctor
must take steps to prevent that
suicide from occurring.
If he fails in this task, he could be
judged guilty of malpractice.

Improper diagnosis or
treatment
While some people believe that many
psychiatric diagnoses are ill-defined, this is
simply not the case.
Any mental health professional should be able
to come to a definitive diagnosis assuming the
proper patient assessment has occurred.
However, if an improper diagnosis is made
or if a doctor prescribes the incorrect
treatment, a patient or their family have a
strong case for malpractice against the doctor
or mental health professional.

Failure to warn
Extending further from the traditional doctor and
patient relationship, courts have ruled that if a
patient makes threats during sessions against
another person, the clinician has a duty to warn this
person of the potential threat if they believe it is
credible.
This can often be a difficult determination for the
clinician as he/she must balance doctor/patient
confidentiality versus their responsibility for the
safety of others.
If a patient acts on these threats, the victims families
have a reasonable malpractice case to pursue.

Boundary violations
It has been established there must
exist a boundary between the
healthcare professional and their
patients.
If the professional violates these
boundaries or attempts to use his/her
position as a means to, for example,
illicit sexual encounters with their
patients, he/she are guilty of
malpractice and maybe even other

False repressed
memories
One of the most common treatments
patients undergo is the process of revealing
past memories that have beenrepressed.
Many psychiatric health care professionals
believe these memories to be the source of
the mental health problems for many
patients.
If false memories are revealed and it
causes irreparable harm to the patient or
other individuals???

Conclusion
Provide the highest standard of
care possible at all times and to
maintain the safety of not only their
patients but any individuals that
have been threatened by the patient.

Informed Consent
Definition: Voluntary acquiescence of medical plan by a
competent patient after the physician adequately discloses
the plan, its risks, benefits and alternative approaches.
Originate from Latin wordconsentire, con=
together;sentire= feel
There should be a harmony of feeling, or joining of
sentiment, between the parties when the permission is granted
It is an act of reason and deliberation, reaching
mutual agreement that is based on an appropriate
understanding and appreciation of the information necessary
to make the decision.

Scenario 1
Mr. A, age of 30 with history of schizophrenia, presented
alone to A&E with symptoms of right iliac fossa pain
subsequently develop intense generalized abdominal pain
with high fever. He was admitted to the surgical unit. The
surgeon recommends urgent surgery for his condition, he
explains the risks and benefits of the proposed surgery as
well as the risks if no treatment was given.
Mr. A claims that there is spirits inside his stomach
causing the severe pain, he states that he recognizes the
surgery is needed to treat his condition and wants it to be
done to release the spirits. Subsequently his thoughts
become disorganized and difficult to follow after the
conversation.
Can he consent to the operation?

Scenario 2
A 54-year-old woman with diabetes and schizophrenia
has been hospitalized with unstable angina, bilateral
heel ulcers, urinary retention caused by an acute
urinary tract infection and anemia caused by a
combination of gastritis and chronic renal failure.
One year ago, she was hospitalized with diabetic
ketoacidosis after reporting that voices told her to
stop taking her insulin. Currently, she is improving but
requires a urinary catheter and must keep her legs
elevated at rest. She says she is now able to take care
of herself and wants to return home.
Does this patient have the capacity to make this
decision?

Informed Consent
For a patient's consent to be informed, three
essential elements must be satisfied:
Decisional capacity
Information disclosure
Voluntarism

Competency
A broad concept, encompassing many different
legal issues and contexts ranging from
treatment decisions, wills, and contracts to
self-representation in trial or guilty plea.
In legal context, it refers to judicial finding
that a person has the mental capacity required
to perform a specific, legally recognized act or
to assume some legal role.

Incompetence
A legal term applied to individuals who are considered by law not
to be mentally capable of performing a particular act or assuming
a particular role
Competency is commonly raised in two situations:
The person is a minor (under age 18)
Mentally disabled

Competency is determined by examining of patients capacity to

the task at hand, it is based on functional capacity of the patient
Law does not regard any particular mental disorder as proxy for
incompetence. Not disease specific! A lack of competency cannot
be presumed from a person's treatment for mental illness or from
institutionalization.

Incompetence
The adjudication of incompetence is issue specific. A
psychiatric patient who is adjudicated incompetent to
execute a will may not be automatically incompetent
to do other things, such as consenting to treatment,
testifying as a witness, marrying, driving, or making
a legally binding contract.
Psychiatrist must determine if any specific functional
incapacities exist that render a person unable to make
a particular kind of decision or to perform a
particular type of task

Levels of Competency
No firmly established criteria exist for
determining a patient's competence
A minimal level of competency must exist,
patient can at least:
1. Understanding and appreciation of particular
disclosed information
2. Make a discernible decision based on reasoning
regarding the treatment that has been offered
3. Communicate that decision verbally or nonverbally.

Necessity to warn patient about

material risks
Obliged to disclose information to the patient, in a
manner that the patient can understand about
The condition
Investigation options
Treatment options
Benefits
All material risk
Possible adverse effects or complications
The residual effects
Likely result if treatment is not taken

Explanatory notes/
document
It is recommended that practitioners provide
additional information on risks and adverse
effects of any procedure in a written
explanatory document which patient/ next-ofkin/ legal guardian can read, request further
explanation where necessary, understand and
append a signature to that effect

Necessity of obtaining
consent
Obtaining an important component of good
medical practice, and also carries specific legal
requirements to do so, except:

Emergencies
Incompetence
Therapeutic privilege
Waiver

Medical emergency
Injury or illness that is acute and poses an
immediate risk to a persons life or long term
health
Consent is not required in emergencies where
The person is unable to consent,
Subject to there being no unequivocal written
direction by the patient to the contrary
No relative or any legal guardian available or
contactable during the critical period to give consent

Medical emergency
Consensus of the primary doctor (who is
managing the patient) and another registered
practitioner is obtained and signs a statement
stating that the delay is likely to endanger the
life of the patient. The registered medical
practitioner must co-sign the consent form.
Specific arrangements apply for the obtaining
of consent from a third party such as parent or
guardian of a child patient

Incapable of, or impaired with,

decision-making ability
Impairments to reasoning and judge which may make it
impossible for someone to give informed or valid consent
include such factors
Basic intellectual or emotional immaturity
High levels of stress such as PTSD
Severe mental retardation
Severe mental illness
Intoxication
Severe sleep deprivation
Alzheimers disease
In a coma

Incapable of, or impaired with,

decision-making ability
Consent must first be obtained from:
The patient himself if he is capable of giving consent as
assessed by a psychiatrist; or
If the patient is incapable of giving consent, from his
guardian in the case of a minor or a relative in the case of
an adult, guardian and relative as defined in the Mental
Health Act
Two psychiatrists, one of whom shall be the primary or
attending psychiatrist, if the guardian or relative of the
patient is unavailable or untraceable and when the patient
himself is incapable of giving consent

Valid informed consent

Must be given by a person with legal capacity, and of
sufficient intellectual capacity to understand the
implications of undergoing the proposed procedure
It must be taken in a language which the person
understands
It must be given freely and voluntarily, and not coerced
or induced by fraud or deceit
It must cover the procedure to be undertaken
The person must have an awareness and understanding of
the proposed procedure and its known or potential risks

Valid informed consent

The person must be given alternate options to the proposed
treatment or procedure
The person must have sufficient opportunity to seek further
details or explanations about the proposed treatment or
procedure
There must be a witness/interpreter, who may be another
registered medical practitioner or a nurse, who is not
directly involved in the management of the patient nor
related to the patient or the medical practitioner, or any
such person who can speak the language of the patient, to
attest to the process during taking the consent

Standard consent form

Patient identification data: Name, IC number, Address,
gender
Name of procedure/ surgery performed in full
Type of anesthesia
Name of registered medical practitioner performing the
procedure/ surgery
Permission to proceed with any additional procedure
that may become necessary during the surgery and
related to the procedure for which the original consent
had been obtained

Standard consent form

A statement to the effect that the person who is performing
the procedure has explained to the patient (or next-of-kin) the
nature of the procedure and the potential material risks
A statement to indicate that the patient has received and read
additional explanatory notes if so provided by the practitioner
Signature of patient/ next-of-kin (relationship) and IC
number and date
Signature of practitioner and name stamp, and date
Signature and name of witness (to the sighing of the form)
and the date

Refusal to give consent for

treatment
A legally competent person has a right to choose what
occurs with respect to his or her own person, regardless
of the reasons of making the choice whether they are
rational, irrational, unknown or even non-existent
Refusal of treatment may be expressed or implied and
may be in writing or given verbally
If the patients circumstances change significantly, any
prior refusal of medical treatment may not remain valid
and may need to be reviewed with the patient

Scenario 1
Mr. A does not have a factual understanding
of the risks and benefits of the recommended
treatment. He does not have an ability to
appreciate his situation and has difficulty
processing information rationally. Overall, he
has deficits in aspects of his decision-making
competence, which could signal the need for
an exception to obtaining informed consent.

Scenario 2
The 54-year-old woman with schizophrenia and multiple
medical problems reported that she was not now
hearing voices nor was she exhibiting any other
psychotic symptoms. She had been very stable on her
psychiatric medications for several months. The patient
understood her medical situation, appreciated the
consequences of care options, analyzed logically the
information she was given and was able to express a
clear choice. She was judged to have capacity. After
learning self-catheterization, demonstrating knowledge
of her medication regimen and agreeing to home
health nursing care, she returned home and returned
for follow-up visits as directed.

Admission to a psychiatric
hospital
Voluntary admission
Patient requests or agrees to be
admitted to the psychiatric ward.
Patient is first examined by a staff
psychiatrist, who determines if he or
she should be hospitalized
Involuntary admission

Involuntary admission
Patient is danger to himself (suicide) or others
(homicide)
Admitted by :
Patients relative
Police officer or other authorized personnel
Prescribed by medical officer (< 5 days before
admission)
Criminals who convicted under Penal Code [Act 574]
and suspected by the court to have mental disorder
(court order)

Mental Health Act 2001

12 parts,94 sections
Introduction
Principles Of MHA
Criteria for detention
Compulsory Admission to Hospital
Patients' rights
Admission of involuntary patient into
psychiatric hospital
Forms

Introduction
As a doctor you are expected to work
with your patient to help them to
make informed choices about where
and what treatment to have.
Under mental health law, as a doctor,
you are able to detain and forcibly
treat individuals against their will.
65

Principles
Purpose principle- To provide for the admission, detention,
lodging, care, treatment, rehabilitation, control and
protection of persons who are mentally disordered and for
related matters.
The Act must be used to minimize the undesirable
effects of mental disorder by maximizing their safety
and wellbeing (mental and physical) of patients,
promoting recovery and protecting others from harm.
Respect principle- People taking decisions under the Act
must recognize and respect each patient including their race,
religion, culture, gender, age, sexual orientation and any
disability.

66

Principles
Participation principle- Patients must be
involved in their care as much as is
practicable. The involvement of care
takers, family and friends is encouraged.
Effectiveness, efficiency and equity
principle- This refers to the most
appropriate use of resources to meet the
needs of patients.
67

Criteria for Detention

under Section 3 of the Act:
1. The person is suffering from a mental
disorder of a nature or degree which makes
it appropriate for them to receive
treatment in hospital.
2. It is necessary for the health and safety
of the person or for the protection of others
3. Appropriate treatment is available
68

Mental Disorder
It is defined as any mental illness, arrested or
incomplete development of the mind, psychiatric
disorder or any other disorder or disability of the
mind. There are no exclusion criteria save for
dependence on drugs or alcohol.
The Code of Practice for the Act states that persons
cannot be considered mentally disordered simply
on grounds of political,religious or cultural
beliefs nor through a persons involvement in
illegal, anti-social or immoral behaviour.

Nature or degree
degree refers to the severity of the
disorder
1.how ill are they and nature refers to
the previous course of that patients
disorder
2. how long and how often have they
been ill, how well have they have
responded to treatment in the past
70

Appropriate for them

appropriate, =the mental disorder is
serious enough, to detain that person
in hospital.
If the mental disorder is not serious
enough, it might be inappropriate to
treat it in hospital and treatment in
the community could be considered

Health and safety of the

person and protection of
others

The health and safety of the person could be

issues such as self neglect, suicidal intent
and impulsive behaviors that lead to a risk
to the patient.
The health of the person includes mental
as well as physical health.
A person can be detained for the protection
of others when a risk has been identified

Patients rights
1. Have their rights given to them at
appropriate times and in an
appropriate format.
2. Detained patients must be
informed of their right to appeal.

73

Others
The MHA applies only to treatment of mental
disorder and cannot be used in treatment of
physical conditions. Unconscious patients are
treated under the auspices of the Mental
Capacity Act 2005.
MD can give leave of absence for pt not
more than 1 mth & revoke the leave of
absence anytime in view of patients
health/safety/ for protection of other persons.
Apprehension if fail to return

Patients Involved in Criminal

Proceedings
Section 37: allows a person convicted of an
imprisonable offence to be detained and treated in
hospital. The patient is discharged when well
regardless of the length of prison sentence they may
have been given if they had not been detained in
hospital
"not guilty by reason of insanity"(person too mentally
disordered to know right from wrong)
"diminished responsibility" can reduce a murder
charge to one of manslaughter
unfit to plead" (person too mentally disordered to
be subject to Court proceedings)

Compulsory Admission to Hospital

Application forms for the compulsory admission
or treatment of a patient must be completed by
nearest relative.
1. approved by the strategic health authority as
having special experience in mental disorder
(usually a consultant or above in psychiatry).
2. at least one doctor should have previously
known patient.
3. at least one doctor should be independent of
the admitting hospital.

Within 24 Hours
Medical director of the psychiatric
hospital should determined whether
or not the continued detention of
the person is justified
It should be done by two medical
officers or registered medical
practitioners, one of them must be
psychiatrist
Should not be done by the doctor who
recommended the admission

Admission of Involuntary Patient into

Psychiatric Hospital
Application by relative (Form 3) OR brought by
police/SWO/Courts + Recommendation by MO/RMP (Form
4/5)
Person brought to a psychiatric hospital
(within 24 hours)
Examine person by MO/MD/RMP
MD have to check back (if examined by MO/RMP) and
decide
not satisfied
satisfied to
continue
detention
discharge
detention not
(Form 6)

order for
exceeding 1 month

before 1/12 deadline

examine by 2 MO/RMP
(1 is a psychiatrist)
discharge
continue detention
not exceeding 3 months
(Form 7)

Discharge
Anytime by MD (for pts best
interest/no need further tx in hosp)
On application by pt / relatives (MD
need to record findings)
*If MD refuses, pt can appeal within
14d to Visitors
Under Rulers pleasure

voluntary

Involuntary-by
relative
Involuntary-by DR

BORANG 11
PEMBERITAHUAN KEPADA MAHKAMAH
BERKENAAN PELEPASAN PESAKIT

BORANG 12
ARAHAN PEMINDAHAN PESAKIT TIDAK
SUKARELA KE HOSPITAL PSIKIATRI YANG
LAIN

84

Mental Health Regulation

2010
9 parts, 53 rules
A psychiatric facility shall ensure that each patient has
a care plan for the management of the patient during
the treatment and upon discharge of the patient
provide a multidisciplinary team consisting of at least
a psychiatrist or
registered medical practitioner with at least one year
experience in psychiatry, a visiting
clinical psychologist or counsellor, a visiting
occupational therapist, nurses or medical
assistants to meet the treatment and psychosocial
rehabilitation needs of patients.

Contents

a) Indication for procedure for seclusion and restrain

b) Restraint area
c) Restraint equipment
d) Application of physical means of restraint (only limbs)
e) Seclusion room (not for <12 y/o)
f) Indication for chemical means of restraints
g) Procedures for chemical means of restraints
h) Indication for physical means of restraints
i) Procedure of physical means of restraints
j) Indication for seclusion
k) Procedure for seclusion
l) Information to be included in the Physical Restraint Record
m) Information to be included in the Seclusion Record

 All doors & windows in patient care

areas of community mental health
centre shall be made of safe and nonhazardous material.
The door shall be able to be locked
and accessible by the staff in an
emergency.
The windows shall have restricted
degree of opening;

ECT
Indication: MDD (with high suicidal risks),
Schizophrenia (with catatonic), Acute Mania,not
response to pharmacological tx
Consent (applicable for surgery) : -pt (if capable)
-relatives
-2 psychiatrists (1 attending psychiatrist) if pt
incapable/ no relatives
PRE E.C.T.
INVESTIGATIONS FBC, BUSE, FBS Chest X-ray
ECG
V/s & fasting

Scenario
A 25 year old students who has a history of
cannabis use and who in the last few months has
become increasingly isolated, missing class and
has been seen by his friends talking to himself.
His roommates take him to see his family doctor
after he is awake all night convinced that the next
door neighbours are listening to his thoughts.
They had to physically restrain him several times
from going around there as he says he could not
cope anymore and wanted to sort them out. He
doesnt think there is anything wrong with him

 Assessment under mental health legislation in

hospital is most likely appropriate in this case.
There appears to be a case of a paranoid
psychosis that warrants further assessment
and treatment.
In Malaysia initially a Form 3 completed by a
relative and a Form 4 would need to be
completed by the medical officer on call. Then
within 24 hrs, after review by a specialist, it
could be converted to a Form 6 allowing
further detention or discharge.