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Predbežné usmernenia v psychiatrickej liečbe a starostlivosť o nedobrovoľne hospitalizovaných pacientov


 | 25.3.2011 | komentárov: 432

Ponúkame Vám preklad článku z časopisu Law and psychiatry od Paula S. Appelbauma, M.D.. Článok sa venuje problematike starostlivosti o nedobrovoľne hospitalizovaných pacientov z psychiatrického hľadiska.

Obrazok Predbežné usmernenia boli v posledných rokoch  jednou zo sľubnejších inovácií, ktorá mala poskytnúť pacientom väčšie slovo pri ich psychiatrickej liečbe. (1) Ak sú spísané, ešte keď sú pacienti svojprávni, predbežné usmernenia umožňujú vymenovať zástupcu s rozhodovacou právomocou a rozhodnúť o jednotlivých ošetreniach. Toto všetko nadobudne účinnosť v prípade, že sa pacient stane nesvojprávnym na to, aby rozhodoval sám za seba. Predbežné usmernenia boli vítané ako spôsob ako podnietiť pacientov a lekárov k diskusii  o budúcich udalostiach a vyjednaniu obojstranne prijateľných prístupov k starostlivosti (2, 3). Všetky štáty majú zákony, ktoré upravujú použitie predbežných usmernení, ktoré môžu byť aplikované vo všeobecnej aj v psychiatrickej starostlivosti a veľa štátov má teraz už aj osobitné ustanovenia o predbežných usmerneniach pre psychiatrickú starostlivosť ako takú.

Odborníci na duševné zdravie mali však vždy obavy, že sa predbežné opatrenia budú používať menej kooperatívnym spôsobom. Jeden z prvých zástancov predbežných usmernení,
Thomas Szasz – zanietený kritik psychiatrických diagnóz a liečby – poukazoval na to, že ľudia s mentálnou poruchou použijú predbežné usmernenia na to, aby vopred zabránili budúcej liečbe, najmä liečbe medikamentmi.(4) Szasz to videl tak, že ak by predbežné usmernenia predstavovali nezmeniteľnú voľbu svojprávnych pacientov, potom by neexistoval žiaden spôsob ako zrušiť preferencie obsiahnuté v usmernení. Tento postreh zvýšil vyhliadky  tej skupiny pacientov, ktorá by mohla byť trvalo neliečená, hoci by boli títo pacienti psychotickí a nedobrovoľne hospitalizovaní. Teraz, v nadväznosti na rozhodnutie Odvolacieho súdu pre druhý obvod  sa zdá byť táto vyhliadka bližšie k naplneniu.

Prípad Hargrave v. Vermont  vyplynul zo sťažnosti podanej v r. 1999 v mene Nancy Hargrave, ženy, ktorá trpela paranoidnou schizofréniou a bola viacnásobne hospitalizovaná vo Vermontskej štátnej nemocnici (5). Pani Hargrave mala vyplnené predbežné usmernenie– vo Vermonte známe ako trvalá plná moc splnomocnenca pre zdravotnú starostlivosť (DPOA) –v ktorom určila zástupcu v prípade, že by stratila spôsobilosť sama sa rozhodnúť a v ktorom odmietla akékoľvek antipsychotické, neuroleptické, psychotropné alebo psychoaktívne lieky. Advokátska kancelária, ktorá zastupovala pani Hargrave, okamžite podala žalobu na štát Vermont, aby mu zabránila zrušiť jej predbežné usmernenie pre prípad, že by bola v budúcnosti opäť nedobrovoľne hospitalizovaná,  a  získala oprávnenie zastupovať celú skupinu pacientov v podobnej situácii.
Terčom pani Hargrave bol zákon 114/1998 Vermontskej zbierky zákonov , ktorý sa pokúsil riešiť dilemu tkvejúcu v predbežných usmerneniach o psychiatrickej liečbe. Aj keď predbežné usmernenia boli určené na uľahčenie účasti pacientov na rozhodovaní o liečbe, tak majú, ako bolo uvedené, potenciál zabrániť akejkoľvek liečbe a to aj u pacientov, ktorí sú chorí natoľko, aby boli podľa prevažujúcich noriem o nebezpečnosti nedobrovoľne hospitalizovaní. Na zmiernenie tejto vyhliadky, Vermontský zákonodarca umožnil personálu nemocnice (alebo väznice) podať na súd návrh o povolenie liečiť nespôsobilého pacienta nedobrovoľne hospitalizovaného bez ohľadu na to, že predbežné usmernenia tvrdia opak. Skôr než súd povolí podanie liekov bez súhlasu pacienta, mal by umožniť, aby sa po dobu 45 dní dodržiavali ustanovenia pacientovho predbežného usmernenia. Takže pacienti ako pani Hargrave, ktorí odmietli všetky lieky, môžu ostať neliečení počas 45 dní, po uplynutí ktorých môže súd zrušiť pacientove odmietnutie liečby .



Jadro námietok pani Hargrave voči zákonu bolo založené na 2. hlave zákona o Američanoch
s postihnutím (Americans with Disabilities Act- ADA), ktorá stanovuje,  že „žiadny jedinec so zdravotným postihnutím, nebude z dôvodu tohto postihnutia vylúčený z účasti na službách, programoch alebo aktivitách verejného subjektu a nemôže byť vystavený diskriminácii zo strany takéhoto subjektu“(6). Pani Hargrave tvrdila, že ona a ďalší členovia jej skupiny boli diskriminovaní na základe duševnej poruchy, vzhľadom nato, že podľa zákona 114  predbežné usmernenie možno zrušiť iba u nedobrovoľne hospitalizovaných osôb s mentálnym postihnutím. A verejné „služby, programy a činnosti“, z ktorých bola vylúčená, bola trvalá plná moc splnomocnenca pre zdravotnú starostlivosť sama o sebe.
V reakcii na to, štát Vermont ponúkol 3 argumenty. Po prvé, keďže pani Hargrave bola nedobrovoľne hospitalizovaná, štát Vermont vyhlásil, že ako osoba, ktorá predstavuje priamu hrozbu, nemôže byť posudzovaná podľa Zákona o Američanoch s postihnutím (ADA). Ďalej tvrdil, že žalobkyňa nebola diskriminovaná na základe mentálneho postihnutia, pretože komukoľvek, kto vyplnil predbežné usmernenie sa môže stať, že jeho alebo jej rozhodnutie (voľa) bude nahradené (štát má alternatívny mechanizmus na jeho zrušenie, a to súdne ustanovenie opatrovníka). V každom prípade bol to status osoby nedobrovoľne prevzatej hospitalizovanej a nie osoby mentálnej chorej, v ktorom spočíval zásadný rozdiel. Nakoniec, sa Vermont pozrel na federálne regulačné ustanovenia, ktoré umožňujú verejnému subjektu pokračovať v existujúcej praxi napriek spochybneniu a návrhu na zmenu Zákona o Američanoch s postihnutím (ADA), pokiaľ by požadovaná zmena zásadne menila charakter, služieb, programov a činností“(7).
Odvolaciemu súdu pre druhý obvod (The Court of Appeal for Second Circuit) sa rovnako ako Okresnému súdu (U.S. District Court), ktorý sa prípadom zaoberal na prvom stupni, zdali všetky tieto argumenty nedostatočne presvedčivé. Pokiaľ ide o konštatovanie, že pani Hargrave a ostatní nedobrovoľne hospitalizovaní pacienti predstavujú priamu hrozbu, trojčlenný senát poznamenal , že nie každý z pacientov by musel byť hrozbou pre iných , ako to požaduje Zákon o Američanoch s postihnutím(ADA), keďže mnohí z nich boli hospitalizovaní, pretože boli nebezpeční pre seba samých. Súd sa domnieva, že dokonca aj osoby, ktoré boli uznané za nebezpečné pre ostatných v čase ich hospitalizácie, nemôžu byť považované za stále nebezpečné v čase, keď sa žiada zrušenie ich predbežného usmernenia.
Súd nebol rovnako presvedčený o tom, že iná okolnosť než duševná choroba bola základom pre rozdielne zaobchádzanie vzhľadom nato, že zákon 114 sa uplatňoval len na osoby s duševnou chorobou. Súd umožnil, aby boli predbežné usmernenia zachované tak ako boli spísané a rozhodol, že dokonca ani fakt, že bol pacient hospitalizovaný, nijako podstatne nemení štatút predbežných usmernení (aj keď by to mohlo mať vplyv na poskytovanie psychiatrickej liečby nedobrovoľným pacientom). Preto súd dospel k záveru, že zákon 114 porušuje zákon o Američanoch s postihnutím (ADA) a zákazal jeho vykonanie .
Pani Hargrave preto stojí za tvrdením, že štát po stanovení právneho základu pre predbežné usmernenia o zdravotnej starostlivosti nemôže z rozsahu jeho uplatnenia vylúčiť nedobrovoľne hospitalizovaných psychiatrických pacientov. Aj keď sa stanovisko odvolacieho súdu vzťahuje len na Vermont a New York, ide o vplyvný súd a jeho stanovisko sa môže odrážať v rozhodnutiach súdov v iných obvodoch. Predbežné usmernenia môžu teraz predstavovať pevný val proti budúcej nedobrovoľnej liečbe s výnimkou mimoriadnych udalostí, dokonca aj pre nesvojprávnych nedobrovoľne hospitalizovaných pacientov, a dokonca aj vtedy, keď alternatívou je dlhodobá ústavná liečba.
V mnohých ohľadoch pani Hargrave predstavuje pokračovanie bitky psychiatrických pacientov o právo odmietnuť liečbu, ktorá začala v roku 1970. Zoznam priateľov súdu (amici curiae), ktorí poskytli stanoviská na podporu pani Hargrave, odzrkadľoval  koalície, ktoré sa na presadenie práva odmietnuť liečbu vyformovali ešte pred 30 rokmi. Táto bitka skončila nejednoznačne.
Aj keď niektoré štáty boli donútené súdmi povoliť, dokonca aj nedobrovoľne hospitalizovaným pacientom okrem pacientov,  ktorí boli súdom vyhlásení za nesvojprávnych, odmietnutie liečby medikamentmi; ostatné štáty naďalej povoľovali ošetrujúcim lekárom (v niektorých prípadoch po získaní druhého názoru) alebo tímu lekárov zrušiť odmietnutie liečby z klinických dôvodov(8). Dokonca aj v štátoch, ktoré vyžadujú vyhlásenie za právne nespôsobilého a posúdenie zástupcu (substituted judgment) o tom, či pacient, keby by bol spôsobilý, liečbu by prijal, drvivá väčšina (obvykle viac ako 90 % ) prípadov prejednávaných pred súdom končia schválením nedobrovoľnej liečby liekmi. Názor
viacerých je taký, že v prípadoch, keď sú pacienti psychotickí a liečba sa zdá byť jasne určená, tak súdy nájdu spôsob ako liečbu odôvodniť niekedy aj napriek právom stanoveným kritériam (8).
Ak by postup v prípade Hargrave prijal širšie, mohol by poskytnúť nástroj, s ktorým by pacienti, ktorí sú odhodlaní zabrániť liečbe liekmi, boli schopní (okrem prípadov núdze) túto liečbu úplne vylúčiť. Odvolací súd by musel uznať ustanovenia predbežnej smernice teraz nesvojprávneho pacienta a nariadiť neposkytnutie liečby. Sudcovia prípadne osoby, ktoré vydávajú rozhodnutia podobné súdnym rozhodnutiam by už viac nedisponovali diskrečnou právomocou uplatniť kritérium „zdravého  rozumu“ -ak by šlo napríklad o liečenie pacientov so zjavnou psychózou -na nariadenie liečby medikamentmi. Dnes málo vážne chorých pacientov odmieta liečbu liekmi, bez ohľadu na právnu úpravu v jurisdikcii, pod ktorú spadajú. Prípad Hargrave to mohol zmeniť. Ak by veľké množstvo pacientov spísalo predbežné usmernenia tak ako Nancy Hargrave s odmietnutím všetkých medikamentov, nemocnice by sa začali plniť pacientmi, ktorých nemôžu liečiť ani prepustiť.

Existujú nejaké právne mechanizmy, ktoré by zabránili takémuto následku bez porušenia Zákona o Američanoch s postihnutím (ADA)? V prípade Hargrave súd sám konštatoval, že nič v tomto rozhodnutí nebráni zákonným revíziám, ktoré by nevyčleňovali osoby postihnuté z dôvodu mentálnej choroby napríklad takým, ktoré by zvyšovali nároky na spôsobilosť pre vyhotovenie DPOA alebo také, ktoré by umožňovali zrušiť DPOA u akejkoľvek nespôsobilej osoby, ak by jej uplatnenie podstatne sťažilo napĺňanie záujmov štátu. Je však otázne, či by zvýšenie prahu spôsobilosti malo nejaký dopad a úprimne povedané, názor súdu týkajúci sa „záujmu štátu“, ktorý by oprávňoval zrušenie predbežnej smernice ktorejkoľvek osoby, je záhadou.
Ale možno by nejaký šikovný zákonodarca dokázal nájsť medzeru a oslabiť dôsledky tohto rozhodnutia. Navyše neexistuje žiadna záruka, že by ostatné súdy alebo dokonca Najvyšší súd USA  nevyhnutne súhlasili s názorom Odvolacieho súdu pre druhý obvod (The Court of Appeal for Second Circuit). Samozrejme, pokiaľ by existoval dostatočný záujem, stále bolo možné, aby Kongres zmenil Zákon o Američanoch s postihnutím (ADA) a vylúčil sporný okruh osôb. Kongres sa však zvyčajne nezvykne zaoberať hlavnými právnymi predpismi a skupina aktivististov pre práva znevýhodnených osôb by pravdepodobne bola proti akýmkoľvek zmenám spomínaného zákona.

Pretože konečný rozsah a dopad tejto kauzy nemusí byť známy skôr než o desať rokov, stojí za to zvážiť možný dopad  rozhodnutia na použitie predbežných usmernení v psychiatrickej liečbe. Aktuálny výskum ukazuje, že väčšina pacientov, ktorá spíše predbežné usmernenia, ich nepoužíva na odmietnutie liečby s medikamentmi, ale skôr na určenie preferencií
pri alternatívnych možnostiach liečby alebo na informovanie budúcich poskytovateľov starostlivosti o konkrétnych otázkach – napríklad o starostlivosti o ich domácich miláčikov počas ich hospitalizácie.

Aj keď prípad Hargrave môže  priniesť nadšenie pre predbežné usmernenia medzi osobami, ktoré odmietajú akékoľvek liečbu liekmi, ešte sa uvidí ako bežným sa stane tento fenomén. Štúdie, ktoré práve prebiehajú nám povedia viac o užitočnosti predbežných usmernení v psychiatrii – napríklad, či majú vzhľadom na súčasný stav systému poskytovania psychiatrickej starostlivosti predbežné smernice dopad na následnú starostlivosť (9). Minimálne to vyzerá tak, že ak sa stane prípad Hargrave známejším, tak pravdepodobne zmrazí nadšenie z psychiatrických pokrokových smerníc u viacerých lekárov. Keďže návrhy lekárov, aby pacienti zvážili spísanie predbežného usmernenia pravdepodobne zohrávajú dôležitú úlohu pri rozhodovaní o  ich vyhotovení (10), môže dedičstvo prípadu Hargrave  brániť v používaní tohto kedysi nádejného nástroja.

zdrojový text: Paul S. Appelbaum, M.D.. Psychiatric Advance Directives and the Treatment of Committed Patients: Law & Psychiatry. July 2004, Vol. 55, No. 7, p. 751-752,763.

autor:
Paul S. Appelbaum, M.D.
preklad: Anton Kapráľ
korektúra: Bc. Zuzana Zoláková

Poznámky:

1. Appelbaum PS: Advance directives for psy- chiatric treatment. Hospital and Communi- ty Psychiatry 42:983–984, 1991
2. Srebnik DS, LaFond J: Advance directives for mental health treatment. Psychiatric Services 50:919–925, 1999
3. Swanson JW, Tepper MC, Backlar P, et al: Psychiatric advance directives: an alterna- tive to coercive treatment? Psychiatry 63:160–177, 2000
4. Szasz T: The psychiatric will: a new mecha- nism for protecting persons against “psy- chosis” and psychiatry. American Psycholo- gist 37:762–770, 1982
5. Hargrave v Vermont, 340 F. 3d 27 (2nd Cir 2003)
6. Americans With Disabilities Act, United States Code, Title 42, Section 12132
7. Code of Federal Regulations, Title 28, Sec- tion 35.130 (b)(7)
8. Appelbaum PS: Almost a Revolution: Men- tal Health Law and the Limits of Change. New York, Oxford University Press, 1994
9. Papageorgiou A, King M, Janmohamed A, et al: Advance directives for patients com- pulsorily admitted to hospital with serious mental illness: randomised controlled trial. British Journal of Psychiatry 181:513–519, 2002
10. Srebnik DS, Russo J, Sage J, et al: Interest in psychiatric advance directives among high users of crisis services and hospitaliza- tion. Psychiatric Services 54:981–986, 2003


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