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At last, our hospitals in British Columbia are using extended leave
Schizophrenia Society of Canada Bulletin, Volume 7, Issue 4, February 1999 |
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Community treatment orders, sometimes referred to as “outpatient committal” - that is, committal outside of hospital - require a history showing the need to ensure compliance to medication. Extended leave (discharge from hospital but still under certification) is one version of it. Reviews are required at stated intervals to verify that the order for a patient is still necessary. Strong follow-up is an essential aspect of community treatment orders’ successful use.
At last, our hospitals in British Columbia are using extended leave. The Ministry of Health is now actively promoting it, and holdouts like St. Paul’s in Vancouver and the main provincial mental hospital, Riverview, can no longer cite untenable administrative reasons for sidelining this issue. Their attitude in the past has both puzzled and angered me. Community treatment orders, of which extended leave is a variation, make eminent sense, both freeing up hospital beds and giving people trying to get back on their feet the protection they need. .
I and many others in British Columbia have been fighting for its implementation for many years now. It’s been on the books as long as I remember, but it was usually neglected in practice - a neglect which produced case history after case history of suffering and tragedy. .
Let me give you just a few examples. Ten years ago, a young Vancouver man suffering from schizophrenia was discharged from Riverview on an extended leave basis, so he was still committed (the hospital, back then, did use extended leave). He went to a supervised group home. He probably shouldn’t have been out of hospital at all. He still had elaborate delusions which sometimes surfaced, an obvious danger signal given he had already suffered two profound psychotic breaks. He also denied there was anything wrong with him. However, while on extended leave, he got his shots regularly and achieved some stability. Then, after six months, his team doctor, naively believing he had established a “relationship” with the young man and this was the key to his care, just couldn’t be bothered renewing the leave certificate. .
Without the requirements of extended leave, his client forthwith didn’t show up for his shots, left the group home which he could no longer cope with, and ended up in a grotty hole of an apartment. The so-called “relationship” which his doctor had talked about simply evaporated. The young man quickly deteriorated even further, becoming floridly psychotic and paranoid. Only his parents, determined not to lose him altogether, kept track of him and tried to get help. Otherwise, who knows what might have happened. He ended up back in Riverview for another long stay, his progress set back to square one yet again....all for the want of extended leave. .
Or another case: a woman with severe bipolar disorder. She had been hospitalized 55 times over 15 years, in Kelowna and Vancouver, her stays in hospital most commonly precipitated by non-compliance. In the last few months of 1996, she was assessed in several emergency departments on five separate occasions, because of suicide attempts. Either her medication wasn’t holding her (the autopsy indicated she had been taking medication) or there had been gaps in the medication which precipitated her actions. Her care team desperately sought to have her readmitted to Riverview, where she had been just a few months earlier, but there was a substantial waiting list and no beds were available. On her last occasion in emergency, at Vancouver Hospital, a psychiatric resident discharged her a few hours after she arrived, when she appeared to be settled. Within a couple of days she attempted suicide again and this time succeeded. .
With her turbulent history, she was just the person to benefit by extended leave. Had it been used in her earlier years, with her medication supervised, she almost certainly would not have passed through the revolving door so many times and her life would have been so much better. Almost certainly, too, in the stages leading up to her death, her care would have been more consistent. It’s also possible that a bed would have been allocated for her at Riverview, since those on extended leave needing re-admission have first call on a bed as it becomes available. .
At the inquest, counsel for the B.C. Schizophrenia Society brought up the need to use extended leave pro-actively. This was the leading recommendation of the jury. .
A third case: Decertification was being discussed for a Riverview patient with a history of several psychotic episodes and of long stays in hospital. His parents were concerned because there was still some delusional content in his thinking. They were appalled that, given his history, including a suicide attempt, the hospital would put him at risk in this way. If he had to be discharged - and he had been in hospital quite a long time - they wanted extended leave to be used. Riverview, however, for untenable administrative reasons, had for several years refused to use extended leave, despite a Ministry of Health instruction prohibiting such a policy. The parents contacted Riverview’s clinical director on the matter, but he refused to budge. Their son was decertified and assigned to a residential cottage on the grounds, run by the Mental Patients’ Association, where medication was not supervised. .
In a couple of months, he began to show signs of deterioration, although he appeared to be compliant. His hours became more and more irregular, which in the past had led to missed doses. The staff at the cottage maintained he was fine. One evening the next month, instructed by voices, he swallowed 20-days worth of medication. Only by happenstance - he had plans for an outing - was he awakened by a staff member late the next morning. He was rushed to hospital with aspiration pneumonia resulting from the overdose. A few hours later and he might well have been dead. Had extended leave been used, on the other hand, closer attention would have been paid to his decline. He also would have been placed in a group home with supervised medication. .
I could relate many more such cases, and most of you reading this article could add your own. Any instance where people are discharged into the community, but don’t have the insight or stability to follow their treatment program, is a situation where a community treatment order is indicated. .
Dr. Don Milliken, the head of psychiatry of the Capital Health Region in Victoria, has pioneered the pro-active use of extended leave. The protocols he developed have worked well, and so has the practice. People who had suffered serious psychotic episodes and been through the revolving door are keeping well because they continue to take their medication regularly and are able to stay in the community. (One of the reasons Riverview cited for its recalcitrance on this issue was that it would have to keep a bed open in each case which, with the pressure on beds, it couldn’t afford to do. The Ministry of Health’s guidelines for extended leave, however, specifically say that holding a bed for a patient on leave is not required. Milliken has pointed out that people on extended leave, where relapse can be averted, don’t usually keep returning to hospital.) .
Other British Columbia hospitals with psychiatric wards are now following suit with extended leave. I know of a woman in North Vancouver, near where I live on the North Shore, who was in and out of hospitals for the better part of 12 years. In the last two years she has been on extended leave and has finally managed a modicum of stability. .
Community treatment orders - either extended leave, as we have here in B.C., or such orders in Saskatchewan - are a key vehicle for helping people with severe mental illness. |
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