Setting

This audit will be relevant to any psychiatrists treating bipolar disorder in either an in-patient or an out-patient setting. It was originally conducted in an inpatient setting with patients admitted with a manic episode.

Background

The National Institute for Health and Clinical Excellence (NICE) recommends that healthcare professionals work collaboratively with patients to make a joint decision regarding treatment and care. Although the standards for this audit were taken from the guidelines for bipolar disorder, the principles could be applied to other disorders.

Standards

The NICE guideline on bipolar disorder (National Institute for Health and Clinical Excellence, 2006) includes the following recommendations:

ᐅ Healthcare professionals should fully involve patients in decisions about their treatment and care, and determine treatment plans in collaboration with the patient, carefully considering the experience and outcome of previous treatment(s) together with patient preference.

ᐅ Advance statements (directives) covering both mental and physical healthcare should be developed collaboratively by people with bipolar disorder and healthcare professionals, especially by people who have severe manic or depressive episodes or who have been treated under the Mental Health Act. These should be documented in care plans, and copies given to the person with bipolar disorder, and to his or her care coordinator and general practitioner.

The Mental Health Act Code of Practice (Department of Health, 2008) indicates that a detained individual is not necessarily incapable of giving consent and the interview at which consent for treatment was sought, as well as the assessment of capacity, should be fully documented in the patient's notes.

Method

Data collection

The medical notes of patients suffering from bipolar disorder and admitted to hospital with a manic episode were examined for the following:

ᐅ documentation of discussion with patients regarding treatment options available and their preference

ᐅ documentation of assessment of capacity to consent to treatment

ᐅ reference to advanced directives if the patient was incapable of consenting

ᐅ advanced directives in the care plan, if the patient was currently incapable of consenting and had had previous episodes or had been detained under the Mental Health Act in the past.

For in-patient settings it might be useful to collect information on current detention under the Mental Health Act or admission to a psychiatric intensivecare unit. This might reflect on the severity of illness and may indicate whether clinical practice varies with the severity of illness, which should not be the case.