Intimacy Recovery: Our Place

Transcription

1 Intimacy Recovery: Our Place P Klassen, Vice-President, Medical Affairs, Ontario Shores Centre for Mental Health Sciences With thanks to B. Walker-Renshaw, BLG 1

2 Disclosure None 2

3 Introduction 1. Rationale for the initiative 2. Policy highlights and challenges 3. Implementation plan 4. Questions for the audience 5. Outcome and next steps 3

4 Ontario Shores Today ~ Ontario Shores Overview ~ A University of Toronto affiliated teaching hospital specializing in mental health and addiction services for those with complex and serious mental illness A Recovery hospital 1,200 employees 349 inpatient beds, extensive outpatient programs, Total budget; $114,017,997.00

5 Intimacy Recovery Policy: Rationale Allalouf inquest (2000) and associated liability issues Not assessing capacity may have implications Jury suggested a minimum standard assessment of capacity, and recognition of the right to sexuality (see also WHO, Canadian Charter of Rights and Freedoms Recovery philosophy The right to full participation, including making mistakes Do we really discuss relationships with our patients? Reality of what happens on inpatient units Patients engage in sexual relations, often without dignity, or due consideration to safety Many patients have been sexually traumatized Focus is on harm reduction 5

6 Status of Patient Sexuality Policy at Ontario Shores Policy (draft) at WMHC created October 7 th, 2002 Patient Sexuality Task Group met January and March, 2009; no outcome Patient sexuality task group struck January, 2011 VPMA Risk Management Admin/Medical director Frontline staff/professional Practice PPAO Patient Experience/Peer Support Clinical Informatics HIM Facilities Management 6

7 Benefits/Risks of Policy and Support of the Policy Consistent with Recovery approach Consistent with reality of inpatient life May improve health of patients Surfaces the issue for clinicians Literature shows that patients benefit, and are not harmed by such discussions Patients identified as incapable may require constant observation, which will add to costs Involves the hospital in making (more) difficult decisions Clinicians anxiety about the issue 7

8 Clinical Issues Patients provided with sexual health education have indicated High levels of satisfaction with the education, and no worsening of symptoms (Herman et al, Psychosocial Rehab., 1994, Steiner et al, HCP, 1994, McCann, Journal of Advanced Nursing, 2000) 50% asked for condoms and more education, vs none before (Goisman et al, Community Mental Health Journal, 1991_ 8

9 Key Questions were Do we support patients engaging in sexual relations at Ontario Shores? Are there groups of patients for whom this is not true? Evaluate capacity to consent to sexual relations on admission for every patient Do we provide education, space and other support for patient sexual relations at Ontario Shores? Room Condoms Education about safe sex, family planning, STDs 9

10 Intimacy Recovery: Task Group agenda 1. Clinical 1. Adapt the 2008 Canadian Guidelines for Sexual education for staff/patients 2. Determine scope of live, and e-learning components 3. Determine seat of advanced clinical expertise (GIM, or on the unit) and lines of authority/response 2. Legal 1. Assessment of capacity for sexual relations 2. Legal review 3. Into Meditech 3. Research 1. Determine the research model/metric(s) to assess outcome 2. Assign a lead and select journals of greatest interest (eg Psychiatric Services) 4. Logistical 1. Space 2. Room bookings 10

11 Tasks accomplished thus far Consensual sexual behaviour of hospitalized patients policy developed and passed Assessment of capacity for sexual relations training for medical staff Training material for front line staff has been created; Understanding Recovery as opposed to personal values Understanding capacity STIs and contraception Stakeholder input Patient and Family Councils are very supportive A space ( Our Place ) was renovated for private time for one or two persons Live April 22 nd,

12 Policy Highlights All patients presumed capable, if 16 years of age or greater Patients will be approached about relationships, intimacy, sexuality, and are assessed for capacity, on admission, and thereafter as may be required The decision about capacity will be communicated to the patient Incapable patients need to be protected Reviewed annually or as required by clinical condition Intimacy suite available for any patient with unaccompanied hospital passes we have forensic patients) 12

13 Other Issues There is no SDM for capacity to engage in sexual relations No advance directives (SCC R v. J.A. 2011) There is no appeal process, but PPAO can assist; decisions made by the team with support from Directors/Recovery Rounds as required Some patients may require higher levels of observation, as a result The space is for any private visiting, not just sexuality 13

14 The Super 8 of Ontario Shores? 14

15 Life in a public hospital 101 Housekeeping hours are an issue Weekends and evenings can be an issue(!) Question of how many hours can be booked at a time etc 15

16 What is sexual activity or intimate relations? It is not limited to sexual intercourse but engages a broad range of activity Criminal Code: Any touching of the body of a person, directly or indirectly, without that person s consent, with a body part of another person, or with an object, for a sexual purpose 16

17 Definition of Capacity A person is capable with respect to a decision if the person is able to understand the information that is relevant to making a decision AND the person is able to appreciate the consequences of a decision or lack of decision applied to their own situation Capacity for sexual relations would be assessed similarly (and presumed capable) Balance of probabilities; does not need to be perfectly certain 17

18 Two Branch Test Capacity depends on having both the ability to understand information the ability to apply information Failure on either branch makes the person incapable In a general psychiatric population, the most common situation is failure on the second branch due to Poor insight Poor behavioural control/disinhibition 18

19 Information Understand and appreciate (future) What is included in the nature of a sexual act? The partner must consent by words and acts, and can change their mind at any time Failure to abide by a partner s wishes is potentially criminal conduct Benefits Intimacy, pleasure, relationships advanced Risks Pregnancy, STIs, emotional issues, trauma reevoked 19

20 When do you re-assess? Capacity should be assessed At reasonable intervals When there is a clinical change (better or worse) When there is a change in treatment When there is a change in setting (e.g. admission) 20

21 Documentation Discussion of diagnosis/condition Look at historical and current status/behaviour Discussion of proposed decision Discussion of purpose/alternatives/remediation Information provided to patient Document consent by way of chart note 21

22 Lessons from the treatment capacity context In addition to the legal test for treatment capacity, we know that: Capacity may fluctuate over time a patient may be capable with respect to a treatment at one time but not at another Capacity may vary depending on the treatment Capacity may be affected by a mental or cognitive disorder that interferes with the person s ability to understand the information relevant to making a decision and the ability to apply that information to him or her self 22

23 Legal tests for capacity to consent to sexual activity In the criminal context: Did the individual make a decision of their own free will, fully aware or informed of the proposed activity and its consequences? Consent requires The ability to understand the sexual nature of the act Knowledge of what the act will lead to in the short and long term 23

24 Legal tests for capacity to consent to sexual activity in criminal context Does the person have the ability to: Understand that their partner may choose to decline to become involved at all or change their mind and withdraw their consent once involved? Understand the risks and consequences associated with the activity that she or he is engaged in? Plan for mitigating or preventing the risks and consequences; or to accept the risks? 24

25 Other consent issues Only the parties to the sexual activity can consent no one can consent on their behalf Inducement to engage in sex by abusing a position of trust, power or authority negates consent A person can express by words or conduct a lack of agreement to engage in the activity Consent may be withdrawn by words or conduct The ability to communicate is essential to consent Is capacity to consent to sexual activity presumptive in the same way as treatment capacity? 25

26 Questions to consider Who would the patient be able to take into Our Place with them? Other patients? Persons from outside? Identified or not? Persons with whom they are in a relationship, or casual sexual partners? Should STI screening be mandatory before Our Place is made available? Is this consistent with Recovery? How would you evaluate outcome Utilization? Satisfaction? 26

27 Challenges Post-Go Live Personal values surface and displace Recovery values Very paternalistic Fear of assessing capacity Doctors avoid the task, need to audit Truly difficult decisions (we have dual diagnosis patients, neuropsychiatry patients, geriatric patients, adolescents, forensic patients etc) Poor dissemination of information as a result Common Bawdy House 27

28 Response to the Challenge of Culture Change Recovery Rounds Senior physician/senior management, professional practice, ethicist, and peer support round daily at 1300 hours to address Recovery concerns Includes Intimacy Recovery Opportunity for education around Recovery values, harm reduction, assessment of capacity etc. Supported by brochures/pamphlets for service users and staff 28

29 Outcome Unfortunately, there have been issues with respect to evaluation, and tracking of use There have been 54 visits, and these have resulted from 10 users Qualitatively, the users are satisfied 7/10 were located and offered a survey All agreed to complete the survey Peer Support led this effort 29

30 Results 30

31 Results cont d 31

32 Next Steps Use began very slowly, and now is growing We will film an instructional video (not specific to our hospital) this fall, addressing and summarizing the issues, for dissemination The video will also provide some guidance on LGTBQ issues, which are a struggle for many staff There is value to choosing a polarizing topic to highlight the need to focus on the service users choices 32

33 Questions? Thanks! 33