Guardian Advocate Training Manual

Guardian Advocate

Training Manual

Prepared by Department of Mental Health Law & Policy

Louis de la Parte Florida Mental Health Institute College of Behavioral and Community Sciences

University of South Florida

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ATTENTION! You must take the Reading Assignment Review Quiz Online for Eam Module

in order to earn your Certificate http://www.dcf.state.fl.us/programs/samh/ment

alhealth/training/index.shtml

3 Activities I Reading Assignment Review Quiz I

0Involuntary Placement Order and Order Appointing Gua 0Where to go for Help

Evaluation -Your opinion matters ..-- -·

4 Certificate of Completion

You must score 100% on all activities to qualify for a certifi

as needed.

Certificate of Completion

Guardian Advocate Manual

Contents

TABLE OF CONTENTS .................................................................................... 2

GENERAL OVERVIEW: .................................................................................... 3

FLORIDA GUARDIAN ADVOCATE TRAINING WEBSITE ............................ 3 Key points to remember ........................................................................................................4 Overview .....................................................................................................................................4 Course Navigation....................................................................................................................4 Reading Assignments .............................................................................................................4 Activities ......................................................................................................................................5 Grades ..........................................................................................................................................5 Resources ....................................................................................................................................5 Certificate of Completion ......................................................................................................5 Security Settings.......................................................................................................................5

CHAPTER 1 ...................................................................................................... 6 Being an Effective Guardian Advocate .............................................................................6 The Reason for a Guardian Advocate ................................................................................7 Responsibilities of a Guardian Advocate .........................................................................7 Types of Appointments..........................................................................................................7 Medical Terms ............................................................................................................................7 Stigmatizing Language ..........................................................................................................7 Non-Stigmatizing Language ....................................................................................................................................8 Legal Terms .................................................................................................................................8 Appointment Qualifications .............................................................................................................................8 Appointment Exclusions........................................................................................................9 Appointment Exclusions........................................................................................................9 Effective Decision Making .....................................................................................................10 Complaints, Grievances,.........................................................................................................11 and Where to go for help.......................................................................................................11

CHAPTER 2 ...................................................................................................... 12 Duties and Decision Making ................................................................................................12 Key Guardian Advocate Duties...........................................................................................13 Additional Duties......................................................................................................................13 Ethical Decision Making Process.........................................................................................14 Access to Clinical Records .....................................................................................................15 Confidentiality ...........................................................................................................................15 Express and Informed Consent ...........................................................................................18 Implied Consent Is Not Enough ..........................................................................................18 Required Treatment and Medication Information .......................................................18 Consent For Treatment ...........................................................................................................18 Informed Consent ....................................................................................................................18 Authorizing Treatment ...........................................................................................................19

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TABLE OF CONTENTS Authorizing Treatment ...........................................................................................................19 Substitute Judgement ............................................................................................................20 Duties of a Guardian Advocate............................................................................................20 Applying Substitute Judgement ........................................................................................20 Difficult Decisions ....................................................................................................................20

CHAPTER 3 ...................................................................................................... 22 Diagnosis, Common Clinical Disorders and Treatment Planning ...........................22 Psychiatric Diagnostic Process.............................................................................................23 Anxiety Disorders .....................................................................................................................25 Types of Treatment ..................................................................................................................25 Anxiety Disorders .....................................................................................................................26 Mood Disorders ........................................................................................................................27 Major Types of Mood Disorders ..........................................................................................27 Types of Treatment for Mood Disorders...........................................................................28 Schizophrenia ............................................................................................................................29 Symptoms of Schizophrenia ............................................................................................................................29 Statistics .......................................................................................................................................29 Types of Treatment for Schizophrenia ..............................................................................30 Treatment Challenges.............................................................................................................30 Assessment & .............................................................................................................................31 Implementation ........................................................................................................................31 The Treatment Plan..................................................................................................................31 Guardian Advocate’s Role in the Treatment Planning ................................................................................................................31 Key Steps in the Clinical Assessment Process ................................................................32 Common Clinical Records Sections ...................................................................................32

CHAPTER 4 ...................................................................................................... 34 Medications and Discharge ..................................................................................................34 Psychotherapeutic Medications ................................................................................................................................35 Generic or Brand.......................................................................................................................36 Anxiety Medications................................................................................................................37 Antidepressants ........................................................................................................................37 Anti-anxiety ................................................................................................................................37 Beta-blockers .............................................................................................................................38 Side Effects..................................................................................................................................38 Bipolar Disorder ........................................................................................................................40 Types of Medications ..............................................................................................................40 Side Effects..................................................................................................................................41 Treatment Effectiveness.........................................................................................................42 Treating Depression ................................................................................................................43 Medication Treatment for Schizophrenia ........................................................................44

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GENERAL OVERVIEW: FLORIDA GUARDIAN ADVOCATE TRAINING WEBSITE

CHAPTER OBJECTIVES ’ To understand the basic layout of the Florida Guardian Advocate Training Modules ’ To understand how to effectively navigate within the site and within each module ’ To be prepared to successfully complete the Florida Guardian Advocate Training Modules


Key points to remember ’ Be patient. There is a lot of information to absorb in an online course - sometimes it can feel overwhelming, especially if you are new to on-line learning.

’ Take your time and always read the information carefully. You’ll find the answers to all course activities within the reading, activities, or resources.

’ You may log in and log out at your convenience. ’ You are not required to complete the module at one time.

Overview There are four modules in the Guardian Advocate training. Each module takes approximately one hour to complete.

Now let’s get started!!! Click Next to continue. Please review all information within this section.

The lessons will briefly cover the following items: ’ Course Navigation ’ Reading Assignments ’ Activities and Grades ’ Resources ’ Certificate of Completion

Course Navigation IMPORTANT: The navigation within the learning lesson is accomplished by using

hyperlinks. You can move forward by clicking ‘‘Next’’ located below or move to an earlier screen by clicking ‘‘Previous.’’

Mouseover - using your mouse point here for more information. Mouseclick - are hyperlinks that open a new window. Close the window when you are ready to return to the lesson.

Reading Assignments All Reading Assignments have questions to check your understanding. Read the question or statement, select your answer, then click the Check Answer button. Be sure to check your answer before moving forward to the next page. When you complete a Reading Assignment, simply close the window and open another topic from the topic outline.

Close T

Reading Assignments are brief. Please complete each assignment before moving to the next reading. All Reading Assignments in the Guardian Advocate modules must be completed before moving to the Activities section. Although Reading Assignments are not graded, they are required.

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Activities provide an opportunity to practice important lessons in this training. There are multiple activities to complete for each lesson. Each activity is brief and contains review questions. You may take the activity as many times as needed to score a 100%. You must complete all activities before you can move to the next training module.

Click the Grades link located on the left menu to view your activity scores. Retake any activity until you score 100%.

Resources provide additional information that might be helpful in your role as a Guardian Advocate. We recommend that you review each resource provided and use it as needed. A glossary is included in the resource section.

You must score a 100% on each activity before you may retrieve your certificate of completion. The certificate is located in the topic outline section. Print and retain a copy of your certificate of completion as a record that you completed each lesson. Also please provide a copy of each certificate to the hospital or crisis unit.

Activities

Grades

Resources Certificate of Completion

IMPORTANT: Please disable all pop-up-blockers for this training. One way to do this is to set the website -http://online-learning1.org/index.html - as a trusted site: 1. Go to Tools 2. Select Internet Options (a pop-up window will appear labeled ‘‘Internet Options’’). 3. Select Security Tab, then click on Trusted Sites within the Security Tab options. 4. Click ‘‘Sites’’ button. This will open up a second pop-up window. 5. It should automatically populate the Add bar, if not type in the address listed above. 6. Click ‘‘Add’’ button, then click close to close second popup window. 7. Click ‘‘Apply’’ button at the bottom of Internet Options pop-up window, then click ‘‘Ok’’ button to close window.

If you are given the option to allow pop-ups, click the highlighted section and select temporarily allow pop-ups for this site.

Security Settings

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CHAPTER 1

Being an Effective Guardian Advocate

CHAPTER OBJECTIVES ’ Identify the three types of Guardian Advocate appointments ’ Give examples of at least three agencies that can provide assistance to a Guardian

Advocate ’ Discuss three options for reporting complaints and grievances

A Guardian Advocate is the informed decision-maker for an individual found by the court to be incompetent to consent to his or her own mental health treatment. The court may authorize a Guardian Advocate to make general and specific medical decisions for the person. This course of instruction provides the necessary information to carry out Guardian Advocate duties.

’ Protect the informed consent rights of the individual held for

examination or treatment, ’ Seek information needed to make informed decisions, and ’ Make decisions concerning treatments that the person would have

made if competent to make his or her own decisions.

This is known as ‘‘substitute judgment.’’ This means that a Guardian Advocate can provide consent for treatment, refuse consent, or revoke previously given consent. In addition to the informed consent rights, Guardian Advocates protect mental health legal rights.

There are three (3) types of Guardian Advocate appointments made by the court:

1. A Guardian Advocate may be appointed for an individual who is incompetent to consent to his or her own mental health treatment at the time of the involuntary placement hearing.

2. A Guardian Advocate may also be appointed to consent to medical treatment a the involuntary placement hearing.

3. A Guardian Advocate may be given additional specific authority at a separate special court hearing to consent to any of the following:

o Abortion, o Sterilization, o Electroconvulsive treatment, Psychosurgery, or Experimental treatments that

have not been approved by a federally approved institutional review board.


The Reason for a Guardian Advocate

Reponsibilities of a Guardian Advocate

Types of Appointments

Congratulations! You completed the Roles and Responsibilities Reading Assignment.

To continue to the next reading assignment, close this window and select another ‘‘Reading Assignment’’ from the topic outline. Begin the ‘‘Activities’’ after completing ‘‘Reading Assignments.’’

The nature of this course requires the use of certain terms from law and medicine. This section will acquaint you with medical and legal terms necessary for use in Guardian Advocacy. Mental illness is a term that refers collectively to all diagnosable mental disorders. Mental disorders are health conditions that are characterized by alterations in thinking, mood, or behavior or some combination associated with distress and/or impaired functioning.

What is a Stigmatizing Language? Stigma is defined as ‘‘a personal characteristic not considered normal or standard by society that detracts from the reputation of a person or group.’’ Individuals with mental illnesses commonly suffer from stigmatization. Terms such as crazy/crazed, nuts, and psycho should not be used to describe a person with a mental health disorder. There are other phrases and terms that should also be

Medical Terms Stigmatizing Language

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Non-Stigmatizing Language

Legal Terms

avoided. For example, a person diagnosed with bipolar disorder should not be described as ‘‘suffering or afflicted.’’ This type of stigmatizing language creates a negative stereotype. A better way to describe this illness is: The man has bipolar disorder. (This is an example of ‘‘person-first language.’’) Always use non-stigmatizing language when referring to mental illnesses and to individuals who receive mental health services. A person who has a mental illness may use one of the following Medical and Legal Terms to describe themselves: ’ consumers, ’ survivors, ’ patients, ’ clients, or ’ recipients

Note: This training uses the term individual or person to refer to the individual appointed a Guardian Advocate. However, when statute is quoted, the word patient may be used. For Example: Schizophrenia is a mental disorder marked by thought distortions (e.g., delusions, hallucinations, incoherence). Depression is a mental disorder marked by mood distortions (anger, sadness). Attention-deficit/hyperactivity disorder is a mental disorder marked by certain behavior (over activity) and/or thought patterns (inability to concentrate). Distortions in thinking, mood, or behavior contribute to a host of problems - primarily personal distress and/or impaired functioning. This training uses the term ‘‘individual’’ or ‘‘person’’ when referring to the individual for whom a Guardian Advocate has been appointed by the Court. However, within Florida Statute, the term ‘‘patient’’ is often used instead.

Congratulations! You completed the Help with Medical and Legal Terms Reading Assignment.


Appointment Qualifications

In selecting a Guardian Advocate, the court must give preference to a health care surrogate. If a health care surrogate has not been designated, the judge makes the selection in the following order:

1. The person’s spouse 2. An adult child 3. A parent 4. The adult next of kin 5. An adult friend 6. An adult trained and willing to serve as Guardian Advocate

Who is a health care surrogate? Note: Circumstances may arise when a judge makes a selection based on other criteria. ’ Agree to the appointment, after being informed of duties and responsibilities. ’ Meet the qualifications of a guardian contained in Chapter 744, Part IV, Florida

Statutes in which the proposed guardian must be a competent adult who has not: o been convicted of a felony o been found to be unsuitable or incapable, due to incapacity or illness,

of

discharging the duties

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o been judicially found to have committed abuse, abandonment, or neglect against a child

o been convicted of or entered a plea of ‘‘no contest’’ to any offense prohibited under F.S. 435.03

o provided substantial services to the individual being held for examination or treatment in a professional or business capacity

o provided credit services to the individual being held for examination or treatment

o been employed in any capacity that provides services to the individual being held for examination or treatment, unless the court determines that the conflict of interest is insubstantial (this exclusion does not apply to the spouse, adult child, parent, or sibling of the individual being held for examination or treatment)

Note: Other conflicts of interest may prohibit the judicial appointment of a Guardian Advocate.

The Baker Act (The Florida Mental Health Act) prohibits (F.S. 394.4598) the following people from serving as Guardian Advocates: ’ A professional that initiates a Baker Act (i.e. physician, clinical psychologist,

psychiatric nurse, clinical social worker, licensed mental health counselor, or marriage and family therapist)

’ An employee of the facility providing direct services to the individual being held

for examination or treatment ’ An employee of the Department of Children and Families ’ A member of the Local Advocacy Council

To view an introductory training on the Baker Act, visit http://www.dcf.state.fl.us/programs/samh/mentalhealth/training/index.shtml.

The Guardian Advocate is required to take a four-hour training course before providing decisions about treatment for an individual involuntarily placed in a mental health facility under the Baker Act. A facility requesting a Guardian Advocate for an individual must provide information to a potential Guardian Advocate about the duties, ethics, and responsibilities involved. The facility must provide adequate health care information before the Guardian Advocate may give express and informed consent for treatment.

Florida Statute 394.4598 - (2) A facility requesting appointment of a guardian advocate must, prior to the appointment, provide the prospective guardian advocate with information about the duties and responsibilities of guardian advocates, including the information about the ethics of medical decision making. Before asking a guardian advocate to give consent to treatment for a patient, the facility shall provide to the guardian advocate sufficient information so that the guardian advocate can decide whether to give express and informed consent to the treatment, including information that the treatment is essential to the care of the patient, and that the treatment does not present an unreasonable risk of serious, hazardous, or irreversible side effects. Before giving consent to treatment, the guardian advocate must meet and talk with the patient and the patient’s physician in person, if at all possible, and by telephone, if not. The decision of the guardian advocate may be reviewed by the court, upon petition of the patient’s attorney, the patient’s family, or the facility administrator.


Appointment Exclusions

Appointment Exclusions

http://www.bakeracttraining.org/

http://www.dcf.state.fl.us/programs/samh/mentalhealth/training/index.shtml

Congratulations! You completed the Do I Qualify for Appointment? Reading Assignment. To continue to the next reading assignment, close this window and select another ‘‘Reading Assignment’’ from the topic outline.

Begin the ‘‘Activities’’ after completing ‘‘Reading Assignments.’’ 9


Effective Decision Making When faced with a serious physical illness, surgery, or other critical medical procedure, a person may need to make difficult decisions. Unfamiliar and stressful situations may seem overwhelming. A Guardian Advocate should obtain as much medical information as possible before making treatment decisions for the individual being held for examination or treatment. Such information would include the benefits and risks of the procedures, alternative treatments, and the probable outcome of these options. What does the Guardian Advocate seek and why? The Guardian Advocate should review the medical progress of the individual being held for examination or treatment on a regular basis. If the current treatment is not helping or causing unacceptable side effects, the Guardian Advocate should contact the doctor and/or medical staff to discuss the situation. If circumstances warrant, the Guardian Advocate may need to consider alternative treatments. In situations when the prescribed treatment is unacceptable and medical staff will not make necessary changes, the Guardian Advocate may need to request a different physician. The Guardian Advocate seeks treatment information and makes decisions about medical care when the individual being held for examination cannot do so for him or herself. Upon appointment a Guardian Advocate should: ’ First obtain a copy of the court order of appointment from the Clerk of the Court

or treatment facility. ’ Carefully review the court order to determine the Guardian Advocate’s scope of

decision-making authority for the individual being held for examination or treatment. This could include:

o medical treatment, o mental health treatment, and/or o court specified medical treatments.

’ Complete the required four-hour Guardian Advocate training or other training as

required by the court. ’ Visit with the individual being held for examination or treatment in the treatment

facility. ’ Speak to the doctor about the his or her condition and treatment. The Baker Act

Preparing for Effective Decision-making requires that this discussion be a face-to-face one if possible --- if not possible, by telephone. The doctor cannot have a staff member do this in his/her place. ’ Review the treatment plan. ’ Keep copies of all signed papers, along with all other important papers related to

the health care of individual being held for examination or treatment. ’ Keep this information confidential. ’ Keep a written record of all interactions with medical personnel concerning the

individual’s condition and treatment.

Congratulations! You completed the Preparing for Effective Decision Making Reading Assignment. To continue to the next reading assignment, close this window and select another ‘‘Reading Assignment’’ from the topic outline.

Begin the ‘‘Activities’’ after completing ‘‘Reading Assignments.’’


A Guardian Advocate should inform the facility personnel of any violations, prefer- ably in writing, keeping a dated copy. A Guardian Advocate may have differences of opinion with the doctor or facility personnel. In most instances these can be resolved by discussion or by writing a letter to the facility.

If a serious unresolved problem places the individual being held for examination or treatment in danger, then promptly contact a proper authority. These agencies include: ’ Florida Adult Protective Services ’ Local Advocacy Council ’ Agency for Health Care Administration ’ Florida Department of Health ’ Florida Department of Children & Families --- Mental Health Services ’ Advocacy Center for Persons with Disabilities ’ Public Defender ’ Circuit Court ’ Family Support and Advocacy Groups

Complaints, Grievances, and Where to go for help

Congratulations! You completed the Complaints, Grievances, and Where to go for Help Reading Assignment.


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CHAPTER 2

Duties and Decision Making

CHAPTER OBJECTIVES ’ Give examples when clinical record information may be released ’ Discuss an ethical decision-making module for Guardian Advocates ’ Explain the requirements for express and informed consent


After completing this four-hour training, the Guardian Advocate should: speak with the individual held in the mental health facility -- in person* if possible speak with his or her psychiatrist -- in person* if possible review the current diagnosis and treatment plan *If in person is not possible then the Guardian Advocate can speak with the individual and physician by telephone.

The Guardian Advocate should: ’ file grievances with the facility when the individual’s rights are violated or a privi-

lege is unjustly denied. ’ approve appropriate mental health and/or medical treatment decisions (as au-

thorized by the court order). ’ approve appropriate mental health and/or medical treatment decisions (as au-

thorized by the court order). ’ request the individual’s transfer from one receiving or treatment facility to an-

other when needed.

The Guardian Advocate may receive and act on notices of: ’ Restriction of communication and/or visitation - Written justification for a

restriction to communicate or to receive visitors must be given to the individual and his or her attorney and Guardian Advocate or legal representative. It must be included in the clinical record and reviewed at least every seven days. The Guardian Advocate should examine the restriction to determine if it is fair and appropriate.

’ Receipt of inventory of personal effects - A person is entitled to possess his or

her clothing and personal effects. If the facility takes custody of these items for medical or safety reasons, an inventory must be provided to the Guardian Advocate. All items must be returned upon transfer or discharge, either to the individual or to the Guardian Advocate.

’ Admission/Release/Transfer Notices- The Guardian Advocate should receive

advance notice of any admission, discharge, or transfer of the individual being held in the mental health facility.

Note: The Guardian Advocate is not responsible for the individual’s financial affairs or securing housing in the community after discharge. ’ Notices of any legal proceedings. ’ Proposed changes to the person’s treatment plan. ’ Complaints - Guardian Advocate may contact and register a complaint with the: ’ The Guardian Advocate can question the legality of the individual’s detention,

report abuse of the individual’s rights, or report abuse of procedures under the Baker Act.

Note: A relative, friend, guardian, representative, attorney, or the Department of Children and Families may also petition for a writ of habeas corpus.

o A member of the facility treatment team o Facility Grievance and Appeal Process Officer o Department of Children and Families (DCF) o Agency for Health Care Administration (AHCA)

o Florida Abuse Hotline o Florida Local Advocacy Council o Advocacy Center for Persons with Disabilities

’ Circuit Court to petition for a writ of habeas corpus

Key Guardian Advocate Duties

Additional Duties

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Beyond medical and/or mental health decisionmaking authority, the Guardian Advocate must receive specific court approval (in a separate hearing) to consent to: ’ Abortion ’ Sterilization ’ Electroconvulsive treatment, Psychosurgery or Experimental treatments that have

not been approved by a federally approved institutional review board The court bases its decision to grant this specific authority on evidence that the treatment or procedure is essential to the care of the person, and that the treatment does not present an unreasonable risk of serious, hazardous, or irreversible side effects.

Congratulations! You completed the Key Guardian Advocate Duties Reading Assignment. To continue to the next reading assignment, close this window and select another ‘‘Reading Assignment’’ from the topic outline.


Ethical Decision Making Process

What is Ethics and Why is it Important? Why is It Important to the Guardian Advocate? As a Guardian Advocate you have to put your feelings and personal beliefs aside when serving as the substitute-decision maker for the individual held in a mental health facility. The following four-step model may assist you in your decision-making role. An Ethical Decision-Making Model for Guardian Advocates Clarify. 1. Determine what must be approved or disapproved regarding treatment 2. Explore alternative treatment options. 3. Eliminate impractical, illegal, and improper options. Evaluate. 1. Evaluate the facts and assumptions carefully, particularly if any treatment options

violate the known wishes or choices of the individual held for treatment. 2. Distinguish facts from beliefs, desires, theories, opinions, and rationalizations. 3. Consider the credibility of sources of information, especially when they appear

self-interested or biased. 4. Carefully consider the benefits, burdens, and risks of each treatment alternative. Decide. 1. Determine what is true (to the best of your ability) and what consequences are most

likely to occur. 2. Evaluate the viable alternatives according to the known wishes or choices of the

individual held for treatment. 3. Determine what option will help the most if the wishes of the individual are un-

known. 4. Consider the worst case scenario if the best option is chosen. 5. Determine whether the treatment benefits of the chosen option outweigh the risks. 6. Consider the following ‘‘ethics guides’’: Are you treating the individual as he or she would want to be treated? Would you be comfortable if your reasoning and decision were publicized?


Implement, Monitor, and Modify. 1. Work with medical professionals to develop a treatment plan. 2. Monitor the effects of the treatment decision. 3. Be prepared to revise a decision, or take a different course of action. 4. Be flexible and open to new information. Adapted from http://www.ethicsscoreboard.com/rb_5step.html

Congratulations! You completed the What is Ethics and Why is it Important Reading Assignment.


What is a clinical record?

It is a written or electronic record of clinical examinations and treatments. It includes dates of medical care, names of physicians and other involved individuals, and medications dispensed. The record documents and evaluates the progress of the person undergoing care. The record is essential should any legal issues arise.

394.4615 Clinical Records; - Confidentiality (1)… ‘‘A clinical record is confidential and exempt from the provisions of s. 119.07(1). Unless waived by express and informed consent, by the patient or the patient’s guardian or guardian advocate or, if the patient is deceased, by the patient’s personal representative or the family member who stands next in line of intestate succession, the confidential status of the clinical record shall not be lost by either authorized or unauthorized disclosure to any person, organization, or agency.’’

Florida Statute 394.455 -- Definitions - Clinical records ‘‘Clinical record’’ means all parts of the record required to be maintained and includes all medical records, progress notes, charts, admission and discharge data, and all other information recorded by a facility which pertains to the patient’s hospitalization or treatment.

This statute is critical -- Baker Act 394.4615(2), F.S. The clinical record shall be released when: (a) The patient or the patient’s guardian authorizes the release. The guardian or guardian advocate shall be provided access to the appropriate clinical records of the patient. The patient or the patient’s guardian or guardian advocate may authorize the release of information and clinical records to appropriate persons to ensure the continuity of the patient’s health care or mental health care.

The Baker Act assures the Guardian Advocate access to the clinical records of the individual held in a mental health facility. It authorizes the Guardian Advocate to release clinical information and records to appropriate individuals to ensure proper physical or mental health care. Authorization to release confidential information should be made cautiously, balancing the individual’s right to privacy against the need for the information.

Access to Clinical Records

Confindentiality

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http://www.ethicsscoreboard.com/rb_5step.html


When clinical record information may be released?

’ When needed by the attorney representing the individual in a mental health facility

’ If Court determines orders the release of records ’ If the individual declares an intention to harm another person, the facility

administrator may release information to provide warning to the threatened person

’ When necessary for clinical treatment or aftercare planning for the individual,

program evaluation, or compilation of treatment data, records may be released to a qualified researcher, aftercare treatment provider, or Department of Children and Families (DCF) employee

’ For purposes of monitoring facility activity, investigating facility complaints or

Medicaid fraud, records may be released to the Agency for Health Care Administration, DCF, or the Florida Advocacy Council

’ The parent or next-of-kin of an individual held mental health facility or program

may request a summary of the person’s treatment plan and current physical and mental condition. Release of this information must be in accordance with the code of ethics of the profession involved.

’ Persons have a legal right to access their clinical records, unless a physician

determines this would be harmful to the person. If a facility restricts the right to review clinical records, written notice of and reasons for the restriction must be given to the person and to the Guardian Advocate. A copy must be placed in the clinical record. A records restriction expires after seven days but can be renewed after review for additional seven-day periods.

’ Confidentiality of Personal Health Information (PHI) is also protected by federal

Health Insurance Portability and Accountability Act (HIPAA) law. If a conflict occurs between HIPAA law and the Baker Act, the law providing the most privacy protection prevails.

Case Study

Paul believes he is a failure at his job and with his family. Lately nothing has brought him joy. He cannot sleep and has lost ten pounds in the last two weeks. He is suicidal and thinks about death all of the time. After he threatened to overdose, his wife, Suzy, called law enforcement. The responding officer initiated a Baker Act and transported Paul to the nearest Baker Act receiving facility. Following the 72-hour examination period, the circuit court determined Paul met criteria for involuntary placement. He was transferred to a treatment facility for up to six months. The circuit court appointed Suzy as his Guardian Advocate. Suzy was granted the authority to approve both medical and psychiatric treatment for Paul. He has hypertension and has a prescription for an ACE inhibitor to treat his blood pressure. Suzy requested to review Paul’s clinical records to verify that he is receiving the ACE inhibitor as prescribed by his primary care physician and to review his treatment plan. The facility staff refused access, citing patient confidentiality.

1. Can the facility legally refuse the Guardian Advocate’s access to clinical records? a. Yes b. No


The Baker Act 394.4615(2), F.S. assures the Guardian Advocate access to the individual’s clinical records. It also authorizes the Guardian Advocate to release information and clinical records to appropriate individuals to ensure the continuity of the person’s mental or physical care. After being refused access to the clinical records, Suzy quoted Baker Act statute 394.4615(2) to the facility staff. Staff advised her that all records are stored electronically and they cannot give her computer access to review them.

2. Can the facility block the Guardian Advocate from viewing electronic records? a. Yes b. No

The law states the Guardian Advocate must have access to clinical records. This includes electronically stored information. For example, the facility could allow the Guardian Advocate to view the information via a secure computer or print the information. Suzy’s mother-in-law is concerned about her son’s hospitalization and wants access to his clinical records. However, Suzy does not believe that Paul would want his mother to view certain details within the records.

3. Is Suzy required to provide Paul’s mother with access to all information in the

records? a. Yes b. No

Suzy may authorize the release of information from the clinical records to appropriate persons only to ensure the continuity care. The Baker Act does not prevent the parent or next-of-kin from requesting a summary of the individual’s treatment plan and current physical and mental condition.

Congratulations! You completed the Access to Clinical Records Reading Assignment.


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Express and Informed Consent

Implied Consent Is Not Enough

Required Treatment and Medication Information

Consent For Treatment

Informed Consent

‘‘Express and Informed Consent’’ means that consent is voluntarily given in writing by a competent person or his/her substitute decision-maker. It must be given without any element of force, deceit, or duress. The Guardian Advocate must make informed (knowing and willing) decisions based on sufficient explanation (disclosure) of all necessary treatment information. A physician is required to use plain language so the Guardian Advocate understands the proposed treatment (including medications). Implied consent involves doing what is suggested or instructed, such as signing paperwork or taking medication without proper disclosure from the treatment team. Implied consent does not mean express and informed consent in Florida. Required Treatment Informaiton: ’ Purpose of treatment ’ Proposed treatment plan ’ Alternative treatment options ’ Potential effects of stopping treatment ’ Approximate length of care ’ Plan for treatment monitoring

Proposed Medication Information: ’ Proposed treatment medications ’ Dosage, administration method, and frequency of medications ’ Common risks and benefits ’ Short-term and long-term side effects ’ Contraindications (pre-existing conditions that may complicate treatment) ’ Significant interactions with other medications ’ Alternative medication options

Consent for treatment may be revoked orally or in writing at any time by the Guardian Advocate on behalf of the individual being held in a mental health facility. Note: The court order specifies whether the Guardian Advocate has the authority to make the mental health and/or medical decisions. Informed Consent is Comprised of two Separate Elements: The first element is disclosure. The physician must disclose all necessary medical information to the Guardian Advocate so that he or she can make well-reasoned treatment decisions. The physician must also answer questions about the proposed and alternative treatments. The second element is consent. Based on the disclosure provided, the Guardian Advocate decides whether or not to provide consent for the proposed treatment. The Guardian Advocate should only sign a consent or other authorization form after receiving disclosure information from the physician or medical staff.

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Whenever possible, the Guardian Advocate should meet with the physician and individual in person prior to signing the consent form. If the meeting cannot be held in person, then a telephone meeting is acceptable.

The following questions should be considered before deciding whether or not to grant consent:

o Will the person be receiving psychotherapeutic medication? o What therapy options, including non-medication alternatives, are available? o Who will be my primary contact on the treatment team? o How will we communicate? How frequently?

A physician may issue an Emergency Treatment Order (ETO) in an emergency situation when the Guardian Advocate is unavailable to provide consent. An ETO may authorize forced medication when the individual held for treatment is endangering him or herself or others. An ETO expires after 24 hours. The physician may renew the order as necessary.

Self-check

1. Name two important elements of informed consent that were discussed in this

reading assignment.

a. Disclosure and consent b. Accessibility and timeliness c. Consent and accessibility d. Timeliness and disclosure e. None of the above

2. The physician has discussed the following treatment components with the

Guardian Advocate: o Purpose of proposed treatment, o Alternative treatment options, o Anticipated length of care and potential effects of stopping treatment.

Did the physician provide sufficient disclosure to make an informed consent decision?

a. Yes b. No

3. Is the physician required to provide the Guardian Advocate with information on

alternative medication(s) which may have fewer side effects?

a. Yes b. No

Authorizing Treatment Authorizing Treatment

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Substitue Judgement

Duties of a Guardian Advocate

Applying Substitute Judgement

Difficult Decisions

What is Substitute Judgment? A court-appointed Guardian Advocate acts as the substitute decision-maker for the individual held in a mental health facility. The Guardian Advocate gives or denies informed consent for treatment when the individual is incapable of making such decisions for him or herself. Ideally, the Guardian Advocate should base treatment decisions on the known preferences of the person being held. If those preferences are not known, the Guardian Advocate must make decisions based on what he or she thinks is in the individual’s best interest.

1. The Guardian Advocate puts aside any personal beliefs to ensure the rights, values, and treatment preferences of the individual are preserved.

2. The Guardian Advocate provides ‘‘substitute judgment’’ for psychiatric treatment and/or medical decisions as authorized by the court.

3. The Guardian Advocate retains these responsibilities until: o the court restores competence to the individual o the court order expires.

If a particular medication appears to be causing harmful side effects, the Guardian Advocate may ask the physician to recommend an alternative medication with fewer side effects. The Guardian Advocate must decide whether to sign any treatment authorization. If the Guardian refuses to allow non-emergency treatment, a legal petition challenging this decision may be filed by the individual’s attorney or family, or by the facility administrator. The court will then review the petition and the Guardian’s decision. If the facility believes a treatment is essential, the facility may petition the court for the appointment of a new Guardian Advocate. As a Guardian Advocate, you should honor the individual’s values and priorities. You should only authorize treatment you believe the individual would choose if he or she was competent. This treatment decision might not be the same you would make for yourself. Best Interest Decision-making: If the Guardian Advocate lacks sufficient information to know what treatment decision the person would have made if competent, the Guardian Advocate must make decisions based on his or her perception of what is in the person’s best interest.

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CROSSWORD Activity: DOWN 1. When signing an authorization for treatment, the Guardian Advocate

the individual being held in a mental health facility.

2. The Guardian Advocate provides substitute for the individual when making psychiatric and/or medical treatment decisions as authorized by the court.

ACROSS 3. are ideas and beliefs that matter to the individual.

4. decision-making involves making healthcare decisions on behalf

an individual who is incapable of doing so for him or herself.

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CHAPTER 3

Diagnosis, Common Clinical Disorders and Treatment Planning

CHAPTER OBJECTIVES

’ Describe the psychiatric diagnostic process. ’ Name three common psychiatric disorders. ’ Discuss two treatment options for common psychiatric disorders. ’ Explain the Guardian Advocate’s role in treatment planning.


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What is a Diagnosis?

The word ‘‘diagnosis’’ originates from a Greek name that means ‘‘to learn, knowledge.’’ Defined --- A medical condition or disease identified by a medical professional based on signs, symptoms, or diagnostic procedures.

A psychiatric diagnosis is based on the symptoms exhibited and responses provided by an individual when interviewed by a psychiatrist. Information in the person’s medical history is also taken into consideration. The diagnosis creates a framework for the person’s treatment. The psychiatric diagnostic process includes: ’ Identifying current symptoms that are causing the individual significant distress. ’ Reviewing the person’s biological, psychological, and social history. The informa-

tion may come from the person, the family, or other treatment facilities. ’ Ruling out any non-psychiatric reasons for the symptoms. A complete physical

examination with the proper lab tests is very important. Physical illnesses can produce symptoms that resemble mental illness. Some medications or street drugs can also produce such symptoms.

When you were an individual’s psychiatric clinical record, you may see several different diagnoses listed. Each diagnosis provides information to help the clinicians plan proper treatment. Mental health professionals use the ‘‘Axis’’ system to help determine the diagnosis and communicate the information below to concerned parties within a mental health facility.

Psychiatric Diagnostic Process

Axis I Clinical disorders, including major mental disorders, and learning disorders Axis II Personality disorders and mental retardation Axis III Acute medical conditions and physical disorders Axis IV Psychosocial and environmental factors contributing to the disorder Axis V Global Assessment of Functioning or Children’s Global Assessment Scale for

children and teens under the age of 18 All diagnostic criteria --- except for physical disorders --- are found in the Diagnostic and Statistical Manual of Mental Disorders(DSM).

After a preliminary diagnosis is made, treatment can begin if the Guardian Advocate provides express and informed consent. The process of arriving at a final diagnosis can take time. A person’s diagnosis may change over time as his or her condition changes or a new professional evaluation is completed.

Review

Prior to providing consent, the Guardian Advocate needs to:

o Review the clinical assessment and proposed treatment plan. o Speak to the attending psychiatrist about the individual’s condition and

treatment. o Speak to the individual being held in the mental health facility to discuss

the proposed treatment plan.


Self-Check

1. What is a diagnosis? a. A written document that outlines the progression of treatment. b. A medical condition or disease identified by a medical professional based on

signs, symptoms, or diagnostic procedures. c. A process to communicate information to the Guardian Advocate and the

individual being held in a mental health facility. d. None of the above

2. Before a providing consent to the proposed treatment, the Guardian Advocate

must speak to both the attending psychiatrist and the individual being held in the mental health facility.

True False

3. After speaking to both the attending psychiatrist and the individual being held in

the mental health facility, the Guardian Advocate must consent to treatment. True False

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MYTH OR FACT Anxiety disorders are the most common mental illness in the United States.

This is a fact. Anxiety disorders affect 40 million adults in the United States, approximately one in five people 18 years and older. (Source: Anxiety Disorders Association of American, http://www.adaa.org)

What is anxiety?

Anxiety is a normal emotion that people experience when facing a challenging problem or stressful situation. Examples include making a difficult personal decision, trying to finish a work project before a deadline, or preparing to take a difficult test.

What is an anxiety disorder?

’ Unlike normal stress or nervousness, an anxiety disorder interferes with a

person’s ability to function in daily life. ’ This severe anxiety must last at least 6 months in order to receive a diagnosis. ’ These disorders can get worse without proper treatment, leaving a person

feeling overwhelmed by fear and worry. ’ Anxiety disorders commonly occur along with other mental or physical illnesses.

Sometimes these other illnesses need to be addressed before the anxiety disorder can be properly treated.

’ Some individuals attempt to cope with severe anxiety by using alcohol or drugs

(either illegal or prescription). Substance abuse can mask anxiety symptoms or make them worse.

’ Symptoms vary depending upon the type of disorder. All these conditions,

however, are marked by excessive, irrational fear and dread.

The different types of anxiety disorders are: (Source: Anxiety Disorders, National Institute of Mental Health, 2009)

o Types of Anxiety Disorders o Generalized Anxiety Disorder (GAD) o Obsessive-Compulsive Disorder (OCD) o Panic Disorder o Post-traumatic Stress Disorder (PTSD) o Social Anxiety Disorder also called Social Phobia o Specific Phobias

’ Medication ’ Psychotherapy ’ Combination of both of the above

In a mental health facility, medication is prescribed by the attending psychiatrist. Antidepressants, antianxiety drugs, and beta-blockers are commonly used to control symptoms of severe anxiety.

Medication While medications cannot cure the disorder, they may enable the individual to lead a productive life despite his or her anxiety. ( The topic of medications will be addressed more fully in the next training module.)

Anxiety Disorders

Types of Treatment


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Anxiety Disorders Psychotherapy While held in a mental health facility, an individual’s treatment plan may include psychotherapy. Also known as talk therapy, counseling, or simply therapy, this treatment involves discussing what feelings, thoughts and behaviors are causing a person’s severe emotional distress and how he or she can cope better in the future. There are many different types of psychotherapy. Cognitive-Behavioral Therapy(CBT) One of the most effective treatment options for anxiety disorders is CBT. Using CBT, individuals learn to recognize and change thinking patterns that generate fears. They also learn healthy new ways of behaving when they do experience an anxiety attack. For example, someone who recently had a panic attack in a grocery store may now avoid grocery shopping altogether. This fear could dramatically affect their life, particularly if they have no one else to go shopping for them. CBT can help teach what triggered the initial panic attack and how to lessen (a) the likelihood of future attacks and (b) the intensity of an another attack that does occur.

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MYTH OR FACT: Depression and bipolar disorder indicate personal weakness. All a person with either of these conditions needs to do is ‘‘think positive’’ and they will feel better.

This is a myth. Depression and bipolar disorder (sometimes called manic-depressive illness) are brain disorders that rarely improve without treatment. Treatment can include medications and/or psychotherapy. Telling someone they are ‘‘weak’’ or just need to ‘‘think positive’’ will probably only make them feel worse.

What is a mood disorder?

There are two (2) basic major categories of mood disorders: ’ Depression (including Major Depression and Dysthymia, a chronic, low-grade

depression) ’ Bipolar disorders (including Cyclothymia, a less intense form of bipolar disorder).

A person with a bipolar disorder experiences intense mood swings between depression and mania.

Most researchers believe mood disorders are caused by chemical imbalances in the brain. Without proper treatment, people with these conditions often experience devastating life events such as marital breakups, job loss, substance abuse, and suicide.

How common are mood disorders?

Approximately one in four women and one in six men will be diagnosed with a mood disorder at some point in their life. Depression is a more common diagnosis than bipolar disorder. The chart below indicates what percentage of men and women are diagnosed with a mood disorder over the course of an average 12 month period and over the course of a lifetime.

Women

over 12 months Women-

over lifetime Men

over 12 months Men

over lifetime Major Depressive Disorder 8.6% 20.2% 4.9% 13.2% Dysthymia 1.9% 3.1% 1.0% 1.8% Bipoloar Disorders 2.8% 4.5% 2.9% 4.3% (Source: National Comorbidity Survey, Harvard School of Medicine)

’ Major Depressive Disorder ’ Bipolar Disorder

For complete diagnostic criteria, please review this information from the U.S. Surgeon General’s office: http://www.surgeongeneral.gov/library/mentalhealth/chapter4/sec3.html

Mood disorders often coexist, or are comorbid, with other mental disorders. For example, according to the Surgeon General’s report on mental health about half of individuals with a primary diagnosis of Major Depressive Disorder also have an anxiety disorder. Likewise, people initially diagnosed with other psychiatric disorders and other Disorders eventually often also experience clinical depression.

Mood Disorders

Major Types of Mood Disorders

http://www.surgeongeneral.gov/library/mentalhealth/chapter4/sec3.html

http://www.surgeongeneral.gov/library/mentalhealth/chapter4/sec3.html


Research demonstrates a link between physical and mental ailments. Individuals with a chronic illness such as heart disease, diabetes, Parkinson’s disease, and Alzheimer’s disease are at greater risk of suffering from depression.

Types of Treatment for Mood Disorders

’ Medication ’ Psychotherapy

Medication Medications used to treat Bipolar Disorders include mood stabilizers, anticonvulsant medications and antipsychotics. The treatment plan may also include antidepressant medications. ( The topic of medications will be addressed more fully in the next training module.) Psychotherapy While held in a mental health facility, an individual’s treatment plan may include psychotherapy. Also known as talk therapy, counseling, or simply therapy, this treatment involves discussing feelings, thoughts and behaviors contributing to a person’s psychological problems. Increased understanding of problems and development of new coping skills can lead to a greater sense of pleasure and control in one’s life.

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MYTH OR FACT An individual diagnosed with schizophrenia has a split personality------or even multiple (more than six) personalities.

This is a myth. Although an individual diagnosed with schizophrania may experience severe and chaotic thought patterns, he or she has only one personlity.

What is schizophrenia?

Schizophrenia is a severe and chronic brain disorder. About one percent of Americans have this illness. Many of these individuals are disabled by their symptoms. While these symptoms vary widely, they often include hearing voices other people don’t hear and believing other people are reading their minds, controlling their thoughts, or plotting to harm them. Faced with these internal disturbances, individuals can become withdrawn or extremely agitated.

Schizophrenia can make it difficult for people to keep a job, take care of themselves, and maintain healthy social relationships. Although treatment often relieves some symptoms of schizophrenia, most people with the disorder must cope with thought disturbances throughout their lives. Despite the challenges, many people can still lead rewarding and meaningful lives in their communities.

What are common symptoms of schizophrenia?

Although every case is unique, characteristics often seen among people diagnosed with schizophrenia include: ’ Delusions - are strongly held beliefs that have no basis in reality. For example,

someone may be convinced the government is spying on them despite no evidence to support this belief.

’ Hallucinations - are sounds and other sensations the person experiences as real

that other people do not. For example, an individual may see and hear someone screaming on a street corner when no one is actually there.

’ Poor verbal communication - Schizophrenia often results in disorganized or

distorted speech patterns or practices. For example, someone may shift rapidly from topic to topic using words that only they understand.

’ Erratic behavior - Schizophrenia often impairs a person’s ability to perform the

tasks of daily life, hold a steady job, and interact with others. For example, an individual may start screaming in reaction to voices they hear in their head.

’ Negative symptoms - refer to the lack of normal behaviors or reactions found in

healthy individuals. For example, a person may remain completely emotionless even when told very good or bad news.

Statistics

o At any given time, approximately one in a hundred American adults------about 2.4 million people------are diagnosed with schizophrenia.

o Men and women are diagnosed with equal frequency. o Men often first exhibit symptoms of schizophrenia in their late teens or early

twenties. For women, it is usually in their twenties or early thirties.

Schizophrenia

Symptoms of Schizophrenia

Statistics


Types of Treatment for Schizophrenia

Treatment Challenges

Types of Treatment o Medication and o Psychosocial therapy

Medication Medication is main treatment option for individuals diagnosed with schizophrenia. Antipsychotic medications are the most commonly prescribed medications in such cases. There are two types of antipsychotic medications: conventional (typical antipsychotics) ans second generation (atypical antipsychotics). It is impossible to predict how an individual will respond to a particular medication. Sometimes a person needs to try several medications before finding the right one. All antipsychotics have potentially harmful and long-term side effects that require careful supervision from a qualified physician. (Medications will be discussed in more detail in the next training module.) Psychosocial Treatment While medication is almost always required for successful treatment of schizophrenia, medication alone is rarely adequate to help people deal with all their life challenges. Assistance is often required to help people cope with illness-related problems, obtain needed services, become more independent, remain on their medication, and avoid future hospitalizations. Two of the more common types of psychosocial services include:

1. Supportive therapy: Individual and group sessions provide illness education and emotional support for people struggling with schizophrenia. The emphasis is on developing problem solving skills, coping with symptoms and medication side effects, improving relationships, and actively participating in one’s own recovery. When possible and appropriate, family members can be incorporated into the recovery process, providing added support for the individual’s recovery and reducing the likelihood of illness relapse.

2. Vocational and social rehabilitation: Teaches basic life skills so individuals can

function better in their personal life and utilize the most of their capabilities in the community. This type of therapy may include training in handling finances, using public transportation, communicating effectively with others, and finding suitable living arrangements. For those willing and able to work, vocational rehabilitation includes job skills assessment and training, and assistance finding full or part-time employment.

Sticking to a treatment plan may be a challenge for an individual diagnosed with schizophrenia. Typical challenges include:

o forgetting to take medications o missing therapy appointments o experiencing a relapse o using alcohol or drugs which can make the symptoms appear worse o experiencing intolerable medication side effects

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Upon an individual’s admission to a mental health receiving facility, the psychiatric treatment team: ’ Gathers information necessary to formulate a psychiatric diagnosis (including the

person’s psychiatric history) ’ Conducts medical, psychological, and social assessments to determine the

individual’s past and current condition and challenges ’ Determines whether the individual is competent to voluntarily consent to

treatment (and if not, who is legally authorized to consent on their behalf )

By law, the receiving facility must complete the treatment plan within five days after the person is admitted under the Baker Act. Team members who commonly contribute to the plan include psychiatrists, nurses, social workers, psychologists, and occupational therapists. In reality, nearly every receiving facility prepares a preliminary treatment plan within 24 hours of a person’s arrival, subject to later completion. Generally, JCAHO and federal standards require a treatment plan much sooner than that required by the Baker Act.

The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) sets standards for healthcare organizations and issues accreditation to organizations that meet those standards.

A treatment plan, including clear goals and measurable objectives, must address the specific factors that triggered the psychiatric crisis and Baker Act admission. If possible, the individual should be allowed to participate in preparing the plan and reviewing it prior to implementation. When a person refuses or is unable to participate in such planning, this fact should be documented in the clinical record.

The Guardian Advocate should be included in the treatment planning process and is legally authorized to view all clinical records. The facility must obtain express and informed consent from the Guardian Advocate for the individual held at a mental heath treatment facility before proceeding with treatment. Discharge planning begins upon admission to the Baker Act facility. Case workers and other staff begin making arrangements to ensure the individual has adequate housing, resources, and psychosocial support upon discharge.

o Review the goals and objectives which serve as markers of progress toward the individual’s recovery and discharge

o Identify which facility staff will provide treatment services o Be aware of challenges to treatment success o Be familar with the person’s medications o Recognize that discharge planning begins early in the treatment process o Be aware that treatment plans may need to be modified based on future

developments o Meet with the individual admitted to the Baker Act treatment facility

Assessment & Implementation

The Treatment Plan Guardian Advocate’s Role

in the Treatment Planning


Key Steps in the Clinical Assessment Process

Common Clinical Records Sections

o Determine severity of mental and substance use disorders o Determine functional impairment due to psychiatric illness o Conduct laboratory testing as needed to determine whether physical o illness is contributing to psychological distress o Identify and contact collateral sources--family, friends, other treatment o providers--to gather additional information o Determine psychiatric diagnosis o Identify additional problem areas to address, either during o hospitalization or after discharge (physical health conditions, housing o needs, vocational training, etc.) o Identify individual’s strengths and sources of social support o Identify cultural and linguistic needs and support

Clinical assessment team members include psychiatrists, nurses, social workers, psychologists, and occupational therapists. Sections commonly found in facility clinical records: Biopsychosocial History: A summary of the person’s medical, psychiatric and personal history used to assess the past and current impact of the illness. Family members and significant others may also be interviewed for background information if possible and appropriate. Assessments: Common assessments include a mental status examination, neurological screening, physical examination, psychiatric evaluation, diagnostic and laboratory tests, and determination of daily functioning. One goal of such evaluations is to determine whether physical illness is causing or masking the mental illness. Psychiatric Diagnosis: Based on symptoms exhibited and responses provided by an individual when interviewed by a psychiatrist. Information in the person’s medical history is also considered. The diagnosis creates a framework for the person’s treatment. Course of Treatment: A brief description of the proposed medical treatment and rehabilitative services to be provided. Treatment objectives should be focused on (1) reducing the severity of symptoms and behaviors responsible for the psychiatric crisis and (2) addressing functional deficits identified in the assessment process. Express and Informed Consent: As specified in the Baker Act, consent to treatment must be obtained and documented before providing treatment. The only exception is when the individual poses an imminent danger to him or herself or others. In such cases a physician may authorize emergency treatment until a court decision can be obtained. Goals and Measurable Objectives: A treatment plan should have several individualized goals, covering social, vocational, housing, or economic aspects of the person’s life. Each goal should have one or more measurable objectives leading towards recovery and improved functioning.

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Daily Progress Notes: Healthcare professionals document the care delivered and the individual’s progress and clinicalstatus over the course of a hospitalization. In addition to allowing treatment team members to communicate with each other, progress notes allow the Guardian Advocate to review case details.

Treatment Team Meeting Notes: Facility staff regularly meet to review the person’s current status, treatment progress, and future plans. If possible and appropriate, the individual and his or her Guardian Advocate should be included in such meetings to provide their input.

Medication Orders: Physician orders must indicate dosage, times per day administered, and whether medicine is a pill,patch, or injection. Except for emergency treatment orders, all prescribed medicationsmust be discussed with the Guardian Advocate before their use (including the need for blood work to monitor certain medications).

Discharge Summary: A brief narrative that summarizes the initial problem, treatments provided, outcomes, future care arrangements, and anticipated progression of recovery.

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CHAPTER 4

Medications and Discharge

CHAPTER OBJECTIVES ’ Discuss why medication effectiveness differs from person to person. ’ Give examples of five factors that can affect medication dosage. ’ Discuss six discharge considerations required by the Baker Act.


Do Psychotherapeutic Medications Cure Mental Illnesses?

Medications are often used to treat symptoms of mental disorders. These illnesses include schizophrenia, depression, bipolar disorder, anxiety disorders, and attention deficit-hyperactivity disorder (ADHD). Psychotherapy and other counseling are sometimes used in addition to medications to treat a person.

Medications used to treat psychiatric conditions are known as psychotropic or psychotherapeutic medications. While these medications can improve distressing symptoms, they do not cure the illness. These medications do help many people with mental disorders live fulfilling lives in the community.

How are medications used to treat mental disorders?

Psychotropic medications do not produce the same results for everyone. For example, one person diagnosed with depression may feel much better after taking a medication for a few months and be able to able to stop taking it. Another person may need to take an antidepressant for many years. Individuals diagnosed with schizophrenia, bipolar disorder, or severe depression or anxiety may need medications for longer periods of time.

What is a side effect?

A medication side effect is an undesirable reaction to taking a prescribed drug. All medications can have side effects. It is difficult to predict how a particular person will react to a particular medication. Side effects may occur when starting or stopping a medication, increasing or decreasing the dosage, or not taking the drug as prescribed.

What can effect medication dosage?

The prescribed medication dose depends on many factors including genetics and whether medications are taken as prescribed. Test your knowledge by trying the activity below.

1. What factor might affect medication dosage.

a. Type of Disorder b. Diet c. Smoking/Drinking d. Supplements e. Age, Sex, Body Size f. Physical Illness g. Other Medications h. All of the above

Psychotherapeutic Medications

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Generic or Brand Generic or Brand, which is better? Brand Name brand medication have a limited patent. When the patent expires, the medication can be manufactured as a generic. In the medication lessons, we list the generic version of the medication first in lower case and the the brand version in parenthesis. For example: haloperidol (Haldol) - haloperidol is the generic and (Haldol) is the brand Generic The generic versions of approved drug are the same as the original brand name drug in terms of:

o active ingredients o strength o dosage requirement o route of administration o label

In addition, the generic form must absorbed and distributed to the part of the body at which it has its effect at acceptably similar levels to the brand name drug. http://www.fda.gov/AboutFDA/Basics/ucm194953.htm TRUE and FALSE Activity 1. Psychotropic medications can cure certain types of mental illness.

True False

2. According to research, the medication dosage for treating mental illnesses should

always be the same for everyone. True False

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http://www.fda.gov/AboutFDA/Basics/ucm194953.htm


What types of medications are used to treat anxiety disorders?

Anxiety disorders include: o Obsessive compulsive disorder (OCD) o Post-traumatic stress disorder (PTSD) o Generalized anxiety disorder (GAD) o Panic disorder o Social phobia.

The most commonly prescribed medications to treat these conditions are antidepressants, anti-anxiety medications, and beta-blockers.

Types of anxiety medications

o Antidepressants o Anti-Anxiety o Beta-Blockers

Antidepressants In addition to treating depression, antidepressants also help people with anxiety disorders. Types of antidepressants include: SSRI, SNRI, Tricylics, buproprion, and MAOI’s. SSRI’s - Prescribed for panic disorder, OCD, PTSD, and social phobia

Fluoxetine (Prozac) Sertraline (Zoloft) Escitalopram (Lexapro) Paroxetine (Paxil) Citalopram (Celexa)

SNRI - Prescribed for GAD

Venlafaxine (Effexor)

Tricyclic - Prescribed for GAD and panic disorder Imipramine (Tofranil)

Buproprion (Wellbutin) - Prescribed for GAD

MAOI’s - Prescribed for anxiety disorders. (People who take MAOI’s must avoid certain foods and medicines that can cause dangerous interactions.)

Phenelzine (Nardil) Tranylcypromine (Parnate) Isocarboxazid (Marplan)

Anti-anxiety Anti-anxiety medications called benzodiazepines are sometimes prescribed to control symptoms of anxiety. While antidepressants can take several weeks to provide relief, benzodiazepines take effect within hours.

Benzodiazepines used to treat anxiety disorders include:

o Clonazepam (Klonopin) - See FDA Warning http://www.fda.gov/Safety/MedWatch/SafetyIn- formation/Safety-RelatedDrugLabelingChanges/ucm154476.htm

o Lorazepam (Ativan) o Alprazolam (Xanax)

Anxiety Medications

Antidepressants

Anti-anxiety

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http://www.fda.gov/Safety/MedWatch/SafetyIn-


Beta-blockers

Side Effects

Beta-blockers Beta-blockers are often prescribed to treat heart conditions and high blood pressure. These medications can also help reduce physical symptoms of anxiety. A doctor may prescribe a beta-blocker on a short-term basis for a person facing a stressful social situation, such as giving a speech. What are the medication side effects? The most common side effects for benzodiazepines are drowsiness and dizziness. Other possible side effects include:

o Upset stomach o Blurred vision o Headache o Confusion o Grogginess o Nightmares

Possible side effects from buspirone (Buspar) include:

o Dizziness o Headaches o Nausea o Nervousness o Lightheadedness o Excitement o Trouble sleeping

Common side effects from beta-blockers include:

o Fatigue o Cold hands o Dizziness o Weakness

Note: Beta-blockers are not generally recommended for people with asthma or diabetes. How should anxiety medications be taken? Over time people can develop a tolerance to benzodiazepines. Higher doses are then needed to get the same effect. Some people also become dependent on these medications. To avoid such problems, doctors usually prescribe benzodiazepines for short time periods. This is especially important for people with substance abuse problems or tendencies. If someone suddenly stops taking benzodiazepines, they may experience withdrawal symptoms or their anxiety may return. Therefore, a person should always gradually taper off these medications. Buspirone and beta-blockers are usually prescribed on a short-term basis. Both should be tapered off slowly. A person should always talk to their doctor before stopping any anti-anxiety medication.

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MULTIPLE CHOICE ACTIVITY 1. What medications are commonly used to treat anxiety disorders?

a. Antidepressants b. Anti-anxiety Medications c. Beta-Blockers d. Antipsychotic Medication e. A, B, and C

MATCHING ACTIVITY 2. Antidepressant a. These medications are used to treat both anxiety disorders

and depression 3. Benzodiazepines b. These medications work quickly to control anxiety

symptoms but can cause sedation 4. Beta-Blocker c. Often used to treat heart conditions and high blood

pressure, these medications also can control anxiety.

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Bipolar Disorder

Types of Medications

What medications are used to treat bipolar disorder? Bipolar disorder, also called manic-depressive illness, is commonly treated with mood stabilizing drugs. These include anticonvulsant, antipsychotic, and antidepressant medications, along with lithium. Types of Medications Lithium Lithium was the first mood stabilizer approved by the Food and Drug Administration (FDA) in the 1970’s for treating both manic and depressive episodes. Mood stabilizers are usually the first medications prescribed to treat bipolar disorder symptoms. Anticonvulsant Medications Anticonvulsant medications were originally developed to treat seizures. They were later found to help control mood swings. Some physicians treat bipolar disorder with these medications. Anticonvulsants work better than lithium for some people. Anticonvulsant medications used to treat bipolar disorder include:

divalproex sodium (Depakote) carbamazepine (Tegretol) lamotrigine (Lamictal) oxcarbazepine (Trileptal)

Atypical antipsychotics Antipsychotic medications are sometimes used to treat symptoms of bipolar disorder. These drugs are often used along with other medications. Antipsychotics used to treat bipolar disorder include:

olanzapine (Zyprexa) aripiprazole (Abilify) risperidone (Risperdal) ziprasidone (Geodon) clozapine (Clorazil)

Antidepressants Antidepressant medications are sometimes prescribed to help treat depression associated with bipolar disorder. Examples of antidepressants used to treat bipolar disorder include:

fluoxetine (Prozac) paroxetine (Paxil) sertraline (Zoloft) escitalopram (Lexapro)

It is potentially dangerous to take antidepressant medications alone for bipolar disorder. Doctors usually prescribe a mood stabilizer or an antipsychotic along with an antidepressant.

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What are the Side Effects? While treatment for bipolar disorder has improved in recent years, it is impossible to predict how an individual will respond to particular medication. Some of the medications can cause serious side effects.

Lithium - If a person is being treated with lithium, the medical team will check blood levels to make sure the kidneys and thyroid are working normally.

o Loss of coordination o Excessive thirst o Frequent urination o Blackouts o Seizures o Slurred speech o Fast, slow, irregular, or pounding heartbeat o Hallucinations o Changes in vision o Itching, rash o Swelling of the face or body.

Anticonvulsant medications - FDA Warning: Anticonvulsants may increase the risk of suicidal thoughts and behaviors. People taking these medications should be closely monitored for new or worsening symptoms of depression or unusual changes in mood or behavior. Other side effects possible with different anticonvulsant medications include:

o Changes in weight o Nausea o Stomach pain o Vomiting o Anorexia o Loss of appetite o Birth defects o Damage to liver or pancreas o Hormone changes (for women and girls) o Skin rashes.

Antidepressants - (see the antidepressant section for more side effect information) Side effects associated with SSRIs and SNRIs include:

o Headache (for the first few days) o Nausea (first few days) o Sleeplessness or drowsiness o Sexual Problems o Agitation or feeling jittery

Antipsychotic - (see the schizophrenia medications lesson for more information on side effects from typical antipsychotics.)

o Drowsiness o Skin rashes o Blurred vision o Rapid Heartbeat o Sensitivity to the sun o Menstrual problems for women o Dizziness when changing positions

Side Effects

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Treatment Effectiveness Is Treatment Effective? Yes. While there is no cure for bipolar disorder, many people benefit from treatment. Medication works best when used as prescribed. As treatment progresses it may be helpful to keep a daily record of an individual’s mood symptoms, sleep patterns, and life events. This information can help everyone involved better treat the illness. Because all medications for bipolar disorder can have serious side effects, it is important to see the doctor on a regular basis. Note: Individuals should never stop taking their medication or change the dosage without first talking to their doctor.

MATCHING ACTIVITY Match the types of medication with the descripted listed below. 1. Mood stabilizers a. Dangerous if used alone to treat bipolar disorder

2. Atypical Antipsychotics b. Most common medication for treating bipolar

symptoms 3. Antidepressants c. Helps reduce hallucinations and delusions

4. Anticonvulsant d. Originally developed to treat seizures, but also helps

control mood swings

MULTIPLE CHOICE 5. Janet’s psychiatrist prescribed Lithium to treat her bipolar disorder. Janet is experi-

encing the following medication side effects: a fast, pounding heartbeat; blurred vision; and occasional hallucinations. She told her Guardian Advocate she feels like she is losing her mind.

What should Janet’s Guardian Advocate do in this situation?

a. Reassure Janet she is fine and her symptoms are to be expected. b. Talk with the medical team about other medication options c. Demand that the doctor stop the lithium immediately.

Congratulations! You completed the Bipolar Disorder Medicaitons Reading Assignment. To continue to the next reading assignment, close this window and select another ‘‘Reading Assignment’’ from the topic outline.


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What medications are used to treat depression?

Antidepressant medications are used to treat depression. Antidepressants affect certain chemicals in the brain called neurotransmitters. These chemicals affect mood and emotional responses.

Are MAOIs dangerous?

People taking MAOIs need to carefully monitor the foods they eat and the medicines they take. Foods and medicines that contain high levels of the chemical tyramine are dangerous for people taking MAOIs. Tyramine is found in some cheeses, wines, and pickles. The chemical is also in some decongestants and over-the-counter cold medicines. People taking MAOIs should ask their doctor for a complete list of foods, medicines, and other substances to avoid.

No two cases are alike. It is impossible to predict how a particular person will respond to a particular antidepressant. It can take up to four weeks for the medication to become effective. People with severe or persistent depression may need to take medication for a long time. Sometimes a person needs to try several medications before finding the right one. The dose may need to be changed to improve effectiveness or reduce side effects. Caution: Even if a person feels better and believes they no longer need treatment, no one should stop taking an antidepressant medication without first talking to his or her doctor. Even under a doctor’s supervision, a person should gradually taper off an antidepressant so the body has time to safely adjust.

Are antidepressant medications safe for adults?

While antidepressants are generally safe, they are not without risk. The U.S. Food & Drug Administration warns that adults taking antidepressants should be watched closely, especially during the first few weeks of treatment. Danger signs include depression that worsens, suicidal thinking or behavior, or changes in behavior such as trouble sleeping, agitation, or social withdrawal. Families and caregivers should report any concerns to the doctor.

Are antidepressant medications safe for children and adolescents? While research indicates many children and adolescents benefit from taking antidepressants, the FDA has issued special warnings regarding the risks for younger persons taking such drugs.

Treating Depression

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Medication Treatment for Schizophrenia

What medications can treat the symptoms of schizophrenia? Antipsychotic medications are used to treat schizophrenia and schizophrenia-related disorders. Older drugs, known as conventional or typical antipsychotics, have been used since the 1950’s. These medications include:

Chlorpromazine (Thorazine) Haloperidol (Haldol) Perphenazine (generic only) Fluphenazine (generic only)

A new group of antipsychotic medications were developed in the 1990s. These new drugs are called atypical antipsychotic medications. They were intended to control an individual’s psychotic symptoms without as many bad side effects. These newer medications include:

Risperidone (Risperdal) Olanzapine (Zyprexa) Quetiapine (Seroquel) Ziprasidone (Geodon) Aripiprazole (Abilify) Paliperidone (Invega)

Long-term use of typical antipsychotic medications may lead to tardive dyskine- sia (TD). This condition causes involuntary muscle movements, especially around the mouth. The symptoms of TD can range from mild to severe. An individual may partially or fully recover after he or she stops taking the medication. For some people, however, the condition is permanent. If other antipsychotics do not improve the schizophrenia symptoms, the physician may prescribe an atypical medication called clozapine (Clozaril). Although effective, clozapine can cause a serious problem called agranulocytosis------a loss of the white blood cells that help fight infection. People who take clozapine must have their blood checked every week or two. WARNING The U.S. Food and Drug Administration (FDA) has warned that death rates are higher for elderly people with dementia who take either typical or atypical antipsychotic medications. Antipsychotic medications are not FDA-approved for the treatment of behavioral disorders in patients with dementia. What are the side effects? Side effects are common when people start taking antipsychotic medications. The side effects below often go away after a few days:

o Drowsiness o Dizziness when changing positions o Blurred vision o Rapid heartbeat o Sensitivity to the sun o Skin rashes o Menstrual problems for women

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How are antipsychotics taken and how do people respond to them?

Antipsychotic medications are most often taken as a liquid or pill. Some antipsychotics can be given as shots once or twice a month.

Some symptoms of schizophrenia, such as agitation and hallucinations, can go away within a few days after starting a medication. Other symptoms such as delusions can take several weeks to go away. Many people report a significant improvement in their condition within two months after starting a medication.

Medication effect is unpredictable It is impossible to predict how a particular person will respond to a particular antipsychotic medication. Sometimes a person needs to try several medications before finding the right one. The dose may need to be changed to improve effectiveness or reduce side effects.

Some people suffer a relapse during which symptoms return or become worse. Relapses usually happen when people suddenly stop taking their medication or don’t take it regularly. Even if a person feels better and believes they no longer need treatment, no one should stop taking an antipsychotic medication without first talking to his or her doctor. Even under a doctor’s supervision, a person must gradually taper off an antipsychotic rather than stopping it suddenly.

What other medications interact with antipsychotics?

Antipsychotics can produce bad side effects when taken with some other medications. Doctors need to know all medications a person is taking, including: ’ prescription and over-the-counter medicines ’ vitamins ’ minerals ’ herbal supplements

People also need to discuss any alcohol or other drug use with their doctor.

MULTIPLE CHOICE Activity 1. Select the two types of medications used to treat the symptoms of schizophrenia.

a. Typical b. Atypical c. Nontypical and Typical d. Both A and B

TRUE and FALSE Activity 2. Side effects associated with antipsychotic medications such as drowsiness, blurred

vision, and rapid heartbeat can often be managed successfully. True False

Congratulations! You completed the Medication Treatment for Schizophrenia Reading Assignment.


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Communi port

Housing


What is Discharge Planning? Every individual is entitled to appropriate treatment after they are discharged from a mental health facility. Discharge planning involves making all necessary arrangements to ensure an individual’s well-being when they return to the community.

Discharge planning links the individual with community-based services, families and friends, and other sources of support to help avoid another hospitalization. This planning begins upon admission to the facility. If possible, the individual should participate in this process.

What is in the Discharge Plan?

Transportation Transportation resources must be included in the discharge planning documentation. The facility may ask the Guardian Advocate to help with transportation needs; however, there is no legal obligation.

Housing Mental health facility staff must request a commitment from a shelter if the individual is at risk of re-admission within three weeks of discharge due to homelessness.

Aftercare The mental health facility provides assistance in obtaining aftercare appointments for case management. These services must be requested to occur within seven days after the expected date of the individual’s discharge.

Medications Psychotherapeutic medications or prescriptions must be provided for a period of up to 21 calendar days or until the first medication appointment (whichever comes first). Medication availability must be considered as part of discharge planning.

Education and Information Written and oral information must be provided on the common side effects of the prescribed medications (including interactions with over-the-counter medications).

Community Support The facility must provide information about and referral to needed community resources. These resources might include:

o Mental Health Treatment Services o Trauma or Abuse Recovery Counseling o Substance Abuse Treatment Programs o Peer Support Groups

What is your role as the Guardian Advocate in Discharge Planning?

As a vital partner in the treatment process, the Guardian Advocate should be involved in discharge planning soon after the person is admitted to the facility. This involvement helps the person receive the best possible care after leaving the facility. It also allows the Guardian Advocate time to make necessary personal plans and arrangements. It is important to note that while the facility may ask the Guardian Advocate to help arrange housing or transportation for the person, these tasks are ultimately not the Guardian Advocate’s responsibility. They are the facility’s legal responsibility.

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Meagan will be discharged from a mental health facility today. The facility was able to schedule her first aftercare appointment with a local community agency 10 days from now.

1. The discharging facility must provide Meagan with prescriptions or supplies of her

medication for the next days. a. 5 b. 10 c. 15 d. 21

Bill has been discharged from a mental health facility. He has an aftercare appointment scheduled within the next 20 days. Bill’s driver’s license was suspended last year.

1. The facility must insure that transportation resources available to Bill are included in

the discharge planning documentation. True False

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Guardian Advocate Training Manual

Documents

Transcript of Guardian Advocate Training Manual