Duties and responsibilities

Expectations of physicians in practice

Medico-legal aspects of providing mental healthcare to patients

Originally published December 2014
P1405-1-E

The prevalence and impact of mental health conditions are receiving considerable attention. Family physicians, psychiatrists, and other healthcare providers play an important role in caring for patients with mental health conditions. As this area of medicine can often intersect with the law, physicians should be aware of the steps they can take to manage the associated risks.

The CMPA experience

The CMPA reviewed its legal and medical regulatory authority (College) cases that closed between 2009 and 2013 and found that 1,308 involved a patient with a mental health condition. The most frequently identified types of medical practice were psychiatry at 47% and family practice at 42%. The top presenting medical conditions were mood disorders; neuroses; stress-related and somatoform disorders; and disorders due to substance use such as alcohol, opioids, and cocaine.

Documentation (31%), communication with patients (15%), and patient evaluation (14%) were the most common clinical issues related to the care provided. These were followed by medication issues such as managing patient pharmacotherapy and physician prescribing practices, and conduct issues such as the blurring of the boundaries in the doctor-patient relationship.

Competent care

Doctors caring for patients with mental health conditions should have the knowledge and clinical competence to appropriately deliver care. The skills include screening for and detecting mental illness; initiating, monitoring, or discontinuing treatment, when appropriate; providing motivational interventions; supporting self-management, as appropriate; and developing links with other partners in care.1

Collaborative care

Patients are more likely to consult their family physician about a mental health concern than any other healthcare provider. Yet, no single provider can be expected to have the knowledge and skills to provide all the care patients may require. When care is delivered in a collaborative approach, the roles of all health providers should be clearly defined, coordinated, complementary, and responsive to the changing needs of patients. Patients are a key component in their care, understanding that the family doctor, psychiatrist, or other providers will remain involved. The patient, or the family, will need to know at all times who the principal contact should be when a particular problem arises.2

Ideally, psychiatrists and other providers recognize and build on the care provided by family physicians. Doctors are encouraged to communicate with each other and with other providers in a timely and appropriate manner. This can mean integrating the mental healthcare plans of psychiatrists with those of family physicians or other providers, and ensuring that all clinical activities are well coordinated for the benefit of patients.3

When collaborating with other mental health providers, physicians should consider the following:4

  • effective communication, including clear and timely information between themselves, other health providers, patients, and families
  • consultation between and among other physicians and mental health professionals, whether in a primary care setting, a mental health facility, a psychiatrist's office, or by telephone
  • coordinated care plans, including monitoring and discharge plans, and clinical activities to avoid duplication and to guide patients to the appropriate programs or resources
  • integration of activities such as shared care planning and decision making, with care being shared according to the respective skills and availability of participants

Patient assessment and diagnosis

It is important to carry out an adequate and effective assessment of patients with mental health conditions. This may include the need for collateral information from the patient's family, when appropriate. To help make a diagnosis, physicians may wish to consult appropriate mental health screening tools, such as those for depression, anxiety disorders, bipolar disorder, and suicide risk. As a mental health condition may rapidly change, appropriate and timely re-evaluation may be required.

Appropriate prescribing

The use of psychotropic medication is on the rise, and physicians should remain vigilant. This is especially important in cases of off-label prescribing or when prescribing medication to children, youth, and seniors. At all times, a consent discussion should be conducted and documented in the patient's medical record. Moreover, physicians and other healthcare providers should monitor patients who are on medication.

Patient handovers

Patient handovers are high risk points in patient care, and require the transfer of adequate and correct information to support patient safety and continuity of care. In hospitals, an important issue to consider when treating patients with mental health conditions is the interaction between emergency physicians and psychiatrists, and between day and night psychiatrists, particularly in relation to patient handovers. Physicians should follow the institution's protocols for handovers, including the transfer of care related to consultations, as well as responsibilities for patient monitoring, treatment, and discharge decisions. And handovers should be documented in the medical record.

Effective and clear communication between healthcare providers is also essential to safe patient handovers in community settings. When multiple physicians and other healthcare providers are involved in caring for patients with mental health conditions, providers should confirm that the reason for the transfer of care is clear to all involved (for example, family physician and psychiatrist). Doctors and other providers should also verify that the roles and responsibilities of each care contributor are clear to the patient and family, as well as to other members of the team.

Consent, privacy, and other considerations

Physicians are always required to obtain consent prior to non-emergent treatment. Consent must be voluntary, patients must have the capacity to consent, and they must be properly informed by their doctors. Patients who are suffering from mental incapacity may still retain sufficient mental ability to give valid consent for medical treatment. Much depends on whether the patient is able to adequately appreciate the nature of the condition, the proposed treatment, its anticipated effect, the alternatives, and the potential consequences of treatment refusal. The laws applicable in most provinces and territories provide a means to obtain substitute consent when the patient is incapable of giving valid consent by reason of immaturity or incapacity. Finally, the determinant of capacity in a minor has become the extent to which the young person's physical, mental, and emotional development will allow for a full appreciation of the nature and consequences of the proposed treatment, including the refusal of such treatments. In Québec, youth can provide consent for care if they have the capacity and are 14 years of age or older. Doctors should be familiar with the applicable legislation in their jurisdiction.

On the privacy front, physicians are well-aware that privacy and confidentiality of patient information is critical. This is equally important when considering mental health information, and particularly relevant due to the stigma that may be associated with these conditions.

In terms of the release of mental health patient information to third parties, there are occasions when a physician's duty to society may outweigh the obligation of physician-patient confidentiality, thereby justifying the voluntary disclosure of information about a patient to the appropriate authority. Facts such as a clear risk to an identifiable person or group of persons, the risk of serious bodily harm or death, and whether the danger is imminent should be considered in determining whether information about a patient may be disclosed without the individual's consent. Physicians should be knowledgeable about applicable legislation and statutes regarding confidentiality and privacy. The CMPA is available for advice in these matters.

Telepsychiatry

As telemedicine grows, more patients access mental health services through interactive videoconferencing, or telepsychiatry. Physicians participating in telepsychiatry should be aware of the salient regulatory, administrative, and clinical issues associated with this form of healthcare delivery.5 These include matters of licensing, credentialing, and jurisdiction; applicable College guidelines or policies; and standards for videoconferencing systems. Physicians should follow any established protocols or procedures specific to each of the telepsychiatry services offered. When orienting a patient to telepsychiatry, consent for this mode of care delivery should be obtained and documented in the medical record. In addition, doctors should be attentive to their communication styles and interactions when using this form of healthcare delivery. Issues of patient assessment, diagnosis, and care planning remain just as important with interactive videoconferencing as in face-to-face encounters.

Risk management tips

The CMPA suggests all physicians caring for patients with mental health conditions consider the following risk management tips:

  • Consider whether the patient should be assessed before treatment decisions are made or before medication is prescribed.
  • Obtain a thorough medical history that includes risk factors (e.g. medications, suicide risk assessment), family history, and collateral information (e.g. medical records, speaking with family) to obtain a comprehensive assessment of the patient. A deficient evaluation can contribute to potential underestimation of the risk for self-harm or harm to others, and the inappropriate prescription or tapering of medications.
  • Obtain informed consent for all non-emergent treatment, including when using electronic communication channels to deliver care, such as telepsychiatry.
  • Document comprehensively, clearly, and at the time of patient contact. When appropriate, documentation should include a clear diagnosis and treatment plan. Medication records should contain justification for any changes made to the patient's medication regime.
  • Communicate to the patient, and family when appropriate, any treatment changes or potential side effects and adverse reaction to prescription medications.
  • Communicate openly, sensitively, respectfully, and professionally with the patient and family.



References

  1. College of Family Physicians of Canada, Canadian Psychiatric Association, "The evolution of collaborative mental health care in Canada: A shared vision for the future," Canadian Journal of Psychiatry (2011) Vol. 56 No. 5
  2. Canadian Psychiatric Association, College of Family Physicians of Canada, "Shared mental health care in Canada: Current status, commentary and recommendations," December 2000. Accessed on June 10, 2014 from: http://www.cfpc.ca/uploadedFiles/Directories/_PDFs/sharedmentalcare.pdf
  3. College of Family Physicians of Canada, Canadian Psychiatric Association, "The evolution of collaborative mental health care in Canada: A shared vision for the future," Canadian Journal of Psychiatry (2011) Vol. 56 No. 5
  4. Ibid
  5. Shore, Jay H., "Telepsychiatry: Videoconferencing in the delivery of psychiatric care," American Journal of Psychiatry (2013) Vol. 170 No. 3. Accessed on July 25, 2014 from: http://ajp.psychiatryonline.org/article.aspx?articleID=1655117

DISCLAIMER: The information contained in this learning material is for general educational purposes only and is not intended to provide specific professional medical or legal advice, nor to constitute a "standard of care" for Canadian healthcare professionals. The use of CMPA learning resources is subject to the foregoing as well as the CMPA's Terms of Use.