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English Language Page Article 5 of Federal Law “On Psychiatric Care” provides for the right of the patient to receive information on the nature of their mental disorder and the therapy methods used in a comprehensible for them manner and taking into account their mental condition (Part 2, Article 5). The majority of the surveyed clinics reported that they always informed their patients of their conditions and discussed with them their therapy methods. Without questioning this statement we will express an assumption that physicians discuss with their patients the nature of their mental conditions and therapy methods in a very laconic form since according to the National Psychiatry Association the majority of patients of psychiatric institutions are unable to answer the question “What were you treated with?” and at best are able to describe the external appearance of medications they took (“they were small and brown” or “they were white, in the form of capsules,” etc.). Physicians’ refusal to provide comprehensive information to the patient is often justified by considerations of protection of patients’ vulnerable mentality. Some physicians admitted that they preferred not to discuss with their patients the peculiarities of their mental illnesses: “we inform those who want to know, but without the diagnosis.” The same approach is used with respect to the treatment: “we do not discuss indications — it is not useful.” At best patients are warned about the potential side effects of the drugs that they take. Article 9 states that patients or their authorized representatives may be provided with information about the status of their mental health and the treatment offered. The article does not directly obligate administrations of institutions to provide such information. At the same time Article 31 of the “Foundations of the RF Legislation on Citizens’ Health Care” does obligate physicians to provide patients at their request with an opportunity to “directly familiarize themselves with medical records reflecting their health status and use these records to consult other specialists.” The majority of physicians are of the opinion that information can be provided only orally, in the form of clarifications, while provisioning the patient with their clinical records is unacceptable. As it has been already mentioned there is an opinion shared by administrators of institutions that this is how physicians take care of patient’s safety (“in order to prevent suicidal attempts” ). Sometimes physicians refer to nonexistent legislative documents when refusing to provide patients with their clinical records and comprehensive information about the status of their health. For example, when doing so physicians of the Bobrovo-Dvorskaya psychiatric clinic of the Belgorod region and the Troitsk psychiatric clinic of the Republic of Buryatia refer to a directive of the Ministry of Health without specifying any details of that normative act. At the same time the currently existing closed nature of medical information is frequently accounted for by the fear that patients “may lose it” or may interpret the provisioned documents incorrectly. One of the leaders of the Central Moscow regional psychiatric clinic #1 has put forth a pseudo-scientific justification of the refusal to provide patients with clinical abstracts: “We strive to help the patient, not to supply them with paper; paper facilitates the development of litigious tendencies in the patient.” In 73% of the surveyed institutions it is almost impossible to obtain an abstract from one’s clinical record (see Appendix 2). The desire to indemnify the patient, the reluctance to approach each patient individually, the neglect and incomprehension of the awareness principle result in a situation when information about the diagnosis, therapy, etc. becomes more accessible to patient’s relatives than patients themselves. This problem is very characteristic of psychiatric institutions and note that in this case rights of the patients are violated twice: first, when patients are denied information, and second when this information is provided to their relatives without patients’ consent, which is a divulgation of medical confidentiality. For example, the Republican neuro-psychiatric dispensary of Kalmykia reported that they do not provision their patients with abstracts from clinical records because they contain information about their relatives, whereas the latter may receive such abstracts. The Oryol regional psychiatric clinic provisions abstracts to patients’ relatives or custodians based on their written petition. The Votkinsk neuro-psychiatric dispensary of Udmurtia makes this information available to “relatives in the interests of the patient.” At the same time interests of relatives often do not coincide with interests of patients, sometimes relatives tend to abuse information provisioned to them from the clinical records of the patient. In some institutions rights of patients are observed better. The Khabarovsk territorial psychiatric clinic provisions abstracts from clinical records only to patients themselves while their relatives may obtain this information only if they provide an authorization to that effect certified by a notary, — “Because how does it work? Today she is wife and tomorrow she is enemy #1 and will use these documents to take away property, child, etc.” The Perm regional and Perm city psychiatric clinics provision their clients with abstracts from their clinical records based on their written requests, whereas an attorney may only receive an abstract if they apply in person, are accompanied by the patient, and succeed in proving that they act in the patient’s interests. The Samara regional psychiatric clinic provisions each patient with an abstract from their clinical record stating the diagnosis and describing the therapy conducted. Note that provision of comprehensive information to patients does not result in the growth of the rate of suicidal attempts among these patients. (Many doctors referred to their concern about the intensification of patients’ suicidal intentions as the primary reason to refuse to provide information to the patient). The RF Ministry of Health Care recognizes the right of the patient to receive information about their health and explains the refusals to provide clinical abstracts by the inertia from old times when psychiatry was a totally closed discipline and no information, and all the more so psychiatric diagnoses, were ever communicated to patients. However, the Ministry of Health Care has not provided an official clarification on this matter. As a result, for example, even the appeals commission that was established by the RF Ministry of Health Care and that operates on the basis of the Moscow Scientific and Research Institute of Psychiatry, does not directly provide patients with documents on results of examinations conducted at their requests but forwards them to psychiatric institutions at their places of residence. As far as information on therapy is concerned, patients receive it within the framework of the previously described “informed consent” procedure. However, instead of fine scientific and diagnostic nuances the information on therapy that is provided to patients should contain comparative data on advantages and disadvantages of various therapy methods, potential risks of complications, side effects, and possible consequences, i.e., forecasts and expenditures. The majority of institutions violate the right of patients to receive information about their health and therapy provided which in many cases prevents them from implementing their rights to therapy at other health care institutions, as well as their rights to education, employment, etc. In addition, possibilities of patients to appeal actions of physicians and their therapy methods become considerably reduced. Awareness of the time, schedule of the day, and internal rules A patient confined to a closed department and limited in their contacts with the external world requires information on time — date, day of the week, time of the day. Therefore each department must have a calendar specifying today’s date, day of the week, and time of the day. Unfortunately, our monitors found neither calendars, nor clocks: as a rule wards contain nothing of the above, while departments rarely have wall-clocks. Information on the schedule of the day and the main rules of the internal order was available on walls of all departments but in some cases the print was too fine to read or positioned in a manner that could not be considered convenient. None of the surveyed psychiatric departments provisioned their patients with printed information in the form of booklets or bulletins. In fact the legal requirement to provide patients with rules of the internal order is complied with but only formally. This is largely accounted for by the fact that the law obligates administrations of institutions to only “provide patients with a possibility to familiarize themselves with rules of the internal order” (Article 39) and does not regulate the form of such familiarization. Awareness of one’s rights Administration and medical personnel of the psychiatric institution must provide patients with a possibility to familiarize themselves with the text of Federal Law “On Psychiatric Care,” as well as addresses and telephone numbers of state authorities, public organizations, and officials that they can apply to should their rights be violated (Article 39). In practice the measures undertaken by administrations of the majority of the surveyed clinics are insufficient and frequently formal. According to interviewed head physicians information on rights is provided to patients at the time of their admission. In the course of the monitoring we found out that there are different methods of providing information on rights to patients. The majority of clinics have information boards with abstracts from Law “On Psychiatric Care” and copies of Article 37, “Rights of Patients of Psychiatric Institutions.” Patients can familiarize themselves with the contents of this article and ask their doctors any additional questions that they may have. In some clinics doctors conduct additional interviews with patients and require them to put their signature to confirm that they have been “notified of their rights and the rules of the internal order” (Astrakhan regional psychiatric clinic, Kirov regional psychiatric clinic named after Bekhterev). Only one institution, Volgograd regional psychiatric clinic #2, reported that their patients receive information on their rights in writing in the form of a specially printed notice on the rights of patient. Oftentimes the text of the law is provisioned to patients at their request. For example, in Khabarovsk city psychiatric clinic named after Professor Galant “there are no specifically organized methods of informing patients of their rights, if they ask a question — we give an answer, while the law they can obtain from a medical nurse.” The same situation is found in some other psychiatric departments: the law is provisioned at the request of the patient or their relatives, but it is not proactively offered. At the same time many doctors are not satisfied with the level of knowledge their patients have of their rights. Some of them remarked that patients know little of their rights and some of them have never even heard of the law. The responsibility of the doctor is to inform the patient of their rights, of their right to refuse to go into therapy offered and invite an attorney, and not to claim that “our patients are not interested in legal problems” to justify their own non-action. To the question of monitors of why there is not a text of the law made available anywhere in the departments, representatives of the Central Moscow regional clinic #1 responded in the following manner: “Everybody knows it.” However head of a department of this clinic confessed during the interview that many of the patients had never even heard of this law. Thus, patients can receive information on their rights practically everywhere but not every institution offers this information proactively. The responsibility of administrations to provide patients with contact information of authorities and organizations that they can forward their complaints to is not fully fulfilled either. For example, in some regions there are commissions established under local health care authorities that deal with patients’ complaints but patients do not suspect such commissions exist (psychiatric department of the Altai republican hospital, Republican neuro-psychiatric dispensary of Kalmykia, etc.), and some physicians are not aware of the existence of such commissions themselves (Kuznetsk city psychiatric clinic of the Penza region, Prokhladnensk district psychiatric clinic of Kabardino-Balkaria). Representatives of the Ukhta city psychiatric clinic of the Komi Republic inform of the possible entities to forward one’s complaint to in the following manner: “Write to the head physician or wherever you want…” To the question of one of the monitors of whether or not they provided appropriate addresses the response was: “They know those addresses themselves.” Such an attitude towards patients’ complaints is associated with the fact that many physicians assume them to be unjustified a priori (Belgorod regional psychiatric clinic, Vladimir regional psychiatric clinic #1 and #4, Irkutsk regional psychiatric clinic, Irkutsk regional neuro-psychiatric dispensary, Magadan regional neuro-psychiatric dispensary, Republican psychiatric clinic of Tatarstan, and some others). It appears that regardless of the contents and justification underlying the complaint psychiatric institutions must help the patient implement their right. In practice institutions assume the responsibility to evaluate complaints and make decisions on them which is illegal and is the prerogative of other authorities. In addition, Federal Law “On Psychiatric Care” protects the right to file complaints and bans censorship (Article 37). In reality however many institutions censor complaints composed by their patients. |
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