Human Rights and Review of the Involuntary Status of Patients with a Mental Illness: Kracke after Momcilovic

Arguably, Australia's most significant judicial pronouncement on the human rights of those with mental illnesses was made in 2009 by Justice Bell, the then President of the Victorian Civil and Administrative Tribunal (“VCAT”). The decision is an exhaustive analysis of the application of the Charter of Human Rights and Responsibilities Act 2006 (Vic) to the involuntary status of a person subject to a community treatment order in Victoria. It occurred in the context of delays in the conduct of reviews of the status of a mentally ill person by Victoria's Mental Health Review Board (“the Board”). The outcome of the hearing was a declaration that the Board had breached the person's human rights to a fair hearing, even though the person's involuntary status on a community treatment order was not disturbed by VCAT. Whilst some important aspects of Justice Bell's decision concerning the general methodology to be applied when analysing human rights were overturned in the subsequent Court of Appeal decision of R v Momcilovic [2010] VSCA 50, the latter decision did not concern mental health and so leaves Kracke as the most detailed articulation and analysis of human rights within this difficult sphere.     

Sexual Surrogate Partner Therapy: Legal and Ethical Issues

The Ben Lewin film The Sessions has drawn attention again to the potential role for sexual surrogate partners and sex workers in enabling persons with disabilities and impairments to give expression to their sexual needs and desires. However, away from the big screen, the ethics of registered health practitioners in themselves engaging in such therapies are highly problematic. Difficult too is the role of such practitioners in being ‘the therapist’ responsible for enabling or brokering sexual contact between their patients and those offering such services for financial reward. In some jurisdictions, arrangements involving sexual surrogate therapy (especially where the therapist benefits from it financially) may not be lawful. Further, in spite of many assertions one way and the other, there are no data enabling evaluation of the success rates of the interventions of sexual surrogates or sex workers. Whether positive outcomes to such interactions are likely in most circumstances, given that the provision of services is predicated upon idealised attachments, is questionable. It is also unclear whether sexual surrogates’ adherence to an ethical code effectively ameliorates the potential for counter-therapeutic consequences from the commodification of intimacy, and it is far from straightforward to identify what steps should be taken by the referring health practitioner to select a suitable provider of sexual services to their patient or client, and then to monitor whether the arrangement is achieving its objectives.     

Early childhood abuse and late-life suicidal ideation

Objectives: In younger populations childhood sexual and physical abuse have been found to be associated with suicidal ideation. Such associations have not been examined among older adults.

Setting: Data from the National Comorbidity Study-Replication (NCS-R).

Participants: Older adults (60+, N?=?1610) from the NCS-R sample.

Measurements: Suicidal ideation occurring after the age of 60 was assessed. Early-life factors were assessed including childhood physical and sexual abuse and parent's internalizing and externalizing symptoms. Participants’ internalizing and externalizing symptoms were also assessed.

Results: Logistic regression analysis showed that male gender, mother's internalizing symptoms and childhood physical and sexual abuse were associated with suicidal ideation. The association between child abuse and suicidal ideation was mediated by participants’ externalizing symptoms.

Conclusions: Health care workers should screen for suicidal ideation among older adults. In particular, older males with externalizing disorders and a history of child abuse may be at a heightened risk for suicidal ideation.     

Increased risk of pneumonia among ventilated patients with traumatic brain injury: every day counts!

Background

Patients with traumatic brain injury (TBI) frequently require mechanical ventilation (MV). The objective of this study was to examine the association between time spent on MV and the development of pneumonia among patients with TBI.

Materials and methods

Patients older than 18 y with head abbreviated injury scale (AIS) scores coded 1–6 requiring MV in the National Trauma Data Bank 2007–2010 data set were included. The study was limited to hospitals reporting pneumonia cases. AIS scores were calculated using ICDMAP-90 software. Patients with injuries in any other region with AIS score >3, significant burns, or a hospital length of stay >30 d were excluded. A generalized linear model was used to determine the approximate relative risk of developing all-cause pneumonia (aspiration pneumonia, ventilator-associated pneumonia [VAP], and infectious pneumonia identified by the International Classification of Disease, Ninth Revision, diagnosis code) for each day of MV, controlling for age, gender, Glasgow coma scale motor score, comorbidity (Charlson comorbidity index) score, insurance status, and injury type and severity.

Results

Among the 24,525 patients with TBI who required MV included in this study, 1593 (6.5%) developed all-cause pneumonia. After controlling for demographic and injury factors, each additional day on the ventilator was associated with a 7% increase in the risk of pneumonia (risk ratio 1.07, 95% confidence interval 1.07–1.08).

Conclusions

Patients who have sustained TBIs and require MV are at higher risk for VAP than individuals extubated earlier; therefore, shortening MV exposure will likely reduce the risk of VAP. As patients with TBI frequently require MV because of neurologic impairment, it is key to develop aggressive strategies to expedite ventilator independence.