Today’s question again takes us to the Mental Health Act 2007 (NSW) s 20. A reminder that this section says:
(1) An ambulance officer who provides ambulance services in relation to a person may take the person to a declared mental health facility if the officer believes on reasonable grounds that the person appears to be mentally ill or mentally disturbed and that it would be beneficial to the person’s welfare to be dealt with in accordance with this Act.
(2) An ambulance officer may request police assistance if of the opinion that there are serious concerns relating to the safety of the person or other persons if the person is taken to a mental health facility without the assistance of a police officer.
The question is:
Olanzapine has recently been introduced for the use in patients who are very anxious and agitated, who are voluntary to seek treatment and volunteer to be given Olanzapine. We are allowed to give 1 dose to be able to assess whether the patient’s behaviour is from an organic cause or from a mental health cause. If it is deemed it is from a mental health cause, we are no longer able to provide Olanzapine as the service is stating that we have to work under the Mental Health protocol and further sedation requires a Section 20 to be enacted.
If our patient continues to be voluntary and willing to attend hospital for their mental health concerns, is there a way that oral sedation can be provided without applying a section 20 as the patient does not require the Section 20? Is there anything in the Mental Health Act that prevents us from providing sedation to a voluntary patient?
Olanzapine is:
… used to treat symptoms of schizophrenia and related psychoses. Olanzapine AN alone, or in combination with lithium or valproate, is used for the short-term treatment of acute manic episodes associated with Bipolar I Disorder.
Olanzapine AN is also a mood stabiliser that prevents further occurrences of the disabling high and low (depressed) extremes of mood associated with Bipolar I Disorder.
I fail to see how so many people read so many words into s 20 that just aren’t there. Section 20 says that an ambulance officer may take a person to a mental health facility if they would benefit from treatment there. The local ED may be 5 minutes away, the mental health facility 30 minutes away, so the ambulance officer can elect to go to the further destination. They can do that even if the person appears to be otherwise well that is they have not illness or injury that requires emergency treatment. Once the ambulance officers have delivered the patient to a mental health facility, the staff of that facility can elect to detain the person based on the ambulance officers observations pending a more complete examination (s 18).
Section 20 says nothing about treatment that can be given. Treatment can be given that the patient consents to or where the patient cannot consent, that is reasonable and in the patient’s best interests.
Section 81 deals with the power to transport people to and from a mental health facility. Section 81(3) says:
A person may be sedated, by a person authorised by law to administer the sedative, for the purpose of being taken to or from a mental health facility or other health facility under this Act if it is necessary to do so to enable the person to be taken safely to or from the facility.
That does mean they could be sedated if they are being treated as an involuntary patient but it does not mean they can only be sedated if they are being treated as an involuntary patient. A patient can be sedated if sedation is indicated by their condition, and they consent to that treatment. Just because a person has a mental illness it does not mean that they cannot give or refuse consent to treatment. Further the Act intends that people who are mentally ill will be involved in their care and medical decision making to the greatest extent possible.
The question
If our patient continues to be voluntary and willing to attend hospital for their mental health concerns, is there a way that oral sedation can be provided without applying a section 20 as the patient does not require the Section 20? Is there anything in the Mental Health Act that prevents us from providing sedation to a voluntary patient?
Again misunderstands s 20. Section 20 doesn’t get ‘enacted’ or triggered. Section 20 is triggered when the ambulance officers decide to take someone to a mental health facility.
Conclusion
If the patient is competent ‘and willing to attend hospital for their mental health concerns’ section 20 has no work to do. Paramedics can provide care that is indicated by the patient’s condition and, with respect to the use of drugs, as permitted by their employer’s practice documents.
If the guidelines say that it is not permissible to give more than one dose then that is what they say. But the reference to s 20 and the idea that somehow s 20 has to be ‘enacted’ is to simply misread s 20 and put lots of words into the section that simply are not there.
This blog is made possible with generous financial support from (in alphabetical order) the Australasian College of Paramedicine, the Australian Paramedics Association (NSW), the Australian Paramedics Association (Qld), Natural Hazards Research Australia, NSW Rural Fire Service Association and the NSW SES Volunteers Association. I am responsible for the content in this post including any errors or omissions. Any opinions expressed are mine, and do not necessarily reflect the opinion or understanding of the donors.\
Australian Emergency Law 
I find this question a little strange, assuming the best interest of the patient is the goal.
I understand the question was, obviously, a legal one but I can’t help but notice clinical issues.
Key points:
1. The patient is voluntary to seek treatment and willing to be transported to hospital
2. They have consented* to treatment with olanzapine and have already taken a dose, presumably 10mg for a healthy adult using the NSW CPG. That’s already at the high end, most best practice guidelines use a range of 2.5-10mg, NSW just starts at the max.
3. Olanzapine has a Tmax of 5 hours and a T1/2 of 33 hours (assuming adequate liver function and non-smoker). I would assume the poster understands the implications of those pharmacokinetic parameters since they’re administering it.
Is it really necessary to give a second dose of a medication that won’t reach peak plasma concentration for 5 hours and still be in the system for several days. The patient has already taken one dose and is willing to be taken to a place of treatment where they can be properly assessed and treated by trained mental health professionals.
Why the need for extra sedation? What’s their SAT score? Maybe I’m misunderstanding the scenario. I’m sure it’s not +3, which would leave you with +1 or +2. The paramedic has already provided oral medication for that doesn’t have immediate effect.
The patient won’t experience the maximal sedative effect for 5 hours, by which stage the paramedic will be long gone. This hypothetical scenario seems to ignore, or be unaware of, the long-term consequences for the patient and the treating mental health professionals.
*Olanzapine is not registered by the TGA for ‘acute behavioural disturbances’ outside of bipolar disorder and Schizophrenia. If true informed consent is to be gained, then best ethical practice would include the discussion about the off-label use of olanzapine. The legal implications, if any, would be best left to a lawyer to answer.
https://catag.org.au/governance-topic/off-label-medicines/