Mental Diseases Ordinance (Mental Health Act of Sri Lanka

NIMH admissions and patient care is governed under the Mental Diseases Ordinance (Last amended as Act 27 of 1956). The current Mental Diseases Ordinances is given as Annexure I in Section F .

Voluntary Admissions

Voluntary Admissions are possible under Section 23 of Mental Diseases Ordinance, An individual should be age sixteen or above to request for voluntary admission. This request is made on the H 68 Form. The Admitting Officer should be satisfied that the voluntary admissions is beneficial to the patient and that he/she has the mental capacity to request admission. For those below sixteen years of age if the guardian is requesting admission it needs recommendation of a Medical Officer.

Involuntary (Temporary) Admissions

Temporary Admissions which are involuntary can be made to NIMH based under Section 28 of the Mental Diseases Ordinance. As per the current practice the Admitting Officer should invoke the Section 28 by filling out the H82 form. This form can be filled by Any Medical Officer allocated for that duty by the Director who has a valid Sri Lanka Medical Council license under section 29 of the Medical Ordinance. As the Ordinance requires two independent signatures the second signature should be made by the Medical Officer of the Ward within 24 hours of admission after an independent assessment of the patient. . All Temporary admissions must be seen by the Consultant Psychiatrist or Unit Senior Registrar or the On Call Senior Registrar within 48 hours of admission. The temporary admission order once affirmed by the Senior Review remains valid for a period of 01 year. When a patient is admitted as a temporary order there should be an application made for admission by the spouse or close relative (next of kin). In the event the spouse or close relative is not available any acceptable person can make the application provided adequate reason is given in writing as to why the next of kin is not available.

The Judgment for Involuntary Admission should be done so based on following criteria: 1. The Patient appears to be suffering from mental illness 2. The patient‘s mental illness requires IMMEDIATE TREATMENT 3. The patient's mental illness can be treated by admission to hospital and treatment is not available in a LESS RESTRICTIVE SETTING 4. Admission to hospital is required for: a. The patient‘s health and safety and b. To prevent deterioration of patient‘s mental or physical state and/or c. For the safety of members of the public 5. The patient has refused or is unable to consent to treatment

The Protocol to follow in Involuntary Admission 1. Ensure the patient‘s medical and psychiatric needs are catered for (i.e. Complete the Psychiatric Case Sheet and initial treatment - H8 Form and if needed PICU Form 2. Ensure the request for admission of a person to an approved mental health unit is filled by next of kin/ other representative 3. Complete the recommendation for admission of a person involuntarily

Admissions via District Courts

District Courts have jurisdiction of the persons that are of unsound mind and their property as per the Mental Diseases Ordinance. As such the District Court has authority to direct admissions to NIMH as the only designated ―Mental Hospital‖ within Sri Lanka. Section 02 to 22 of the Mental Diseases Ordinance, deal with District Court Admissions. Admissions sent by the District Court should not be refused by the Admitting Officers unless in exceptional circumstances where such decision will be taken by the Director and relevant Consultant Psychiatrist. The learned District Judge of Colombo will review patients admitted to NIMH by District Court order once in every two week and wards must forward the patient before the court with a report from the Consultant Psychiatrist whether the patient is of sound or unsound mind. Wards can use the standard court report format developed for this purpose. Those reported as sound mind will be released by courts following due process.

Admissions via Magistrate or High Courts

Magistrate and High Courts will refer admissions to NIMH for those having an alleged criminal offense and suspected to have mental illness. Such admissions will be received by the Forensic Psychiatry Unit. Magistrate Courts sometimes function as hybrid District Courts on service needs and the Admitting Officer can clarify the order by looking at the charge. If the Court order carries an AR or LY number with a charge of Insanity or of Lunacy then it is a civil case and can be admitted to general wards. Any queries regarding these can be clarified with the Forensic Psychiatric Team.

Involuntary Treatment

Patients admitted by District Courts, Magistrate Courts or as temporary admissions are subjected to involuntary treatment. This is to state that the patient‘s consent is not needed to provide the necessary treatment. This is primarily regarding the treatment of mental illnesses. Treatment of other physical illnesses also can be done on an involuntary basis provided the Medical Officers are satisfied that the patient does not have the capacity to decide on his/her treatment.

The capacity for the patient to give consent will be decided by the Consultant Psychiatrist.

If a patient is admitted voluntarily and the treating team identifies that the patient‘s mental state has changed to the state where involuntary treatment is indicated such a decision should be taken by the Consultant Psychiatrist and approval of the Director taken after filling the H82 form.

Patients who do not have capacity to give consent for invasive procedures and surgeries a recommendation of the treating Consultant for the procedure and consent of the Director is required for the procedure to be performed. Decisions taken to intervene as lifesaving urgent procedures by Medical Officers are accepted.

When a decision is taken by any Medical Officer with regard to involuntary treatment it is of paramount importance to remember the fundamentals of Medical Ethics.

1. Beneficence - Decisions must be taken in the best interest of the patient to do good to him/her. 2. Non-Maleficence - Decisions must be taken without prejudice or ill will and no harm should be done purposefully. 3. Autonomy - Though the patient does not have the capacity to decide, his/her individuality, privacy and dignity must be respected as much as possible. 4. Justice - Decisions must be taken in a just and fair manner.

As the institution provides involuntary treatment the following risks to the patients must be mitigated by all staff. It is a fiduciary responsibility of all as most patients are detained against their will. NIMH is accountable to the Republic and the next of kin of the patient to ensure the safety of the patient. As such the following risk of the patient should be assessed on admission and periodically and appropriate corrective action taken.

1. Absconding Risk 2. Suicidal and Self Harm Risk 3. Homicidal and Violence Risk 4. Medical Risk 5. Fall Risk

A patient should be given the right if requested to appeal against involuntary treatment to the Director NIMH or Director General of Health Services. Such a request may be reviewed by a panel of experts appointed by the Director - NIMH or DGHS. District Court and Magistrate Court orders are subject to review by the Court of Appeals and Supreme Court.