|
English Language Page 2.3.1. General data The Neuro-Psychiatric Hospital in Negorci is a regional hospital, located near Gevgelija and serving the regions of Veles, Kavadarci, Stip and south with an overall population of 400-500 thousand inhabitants. It was established in 1970 and had a capacity of 300-350 beds. On the day of the visit it hosted 220-240 patients. For the entire 2003 the hospital treated 589 patients, of which 399 were admitted for treatment during the year. Of them 157 were new patients with first hospitalizations. 149 patients had spent more than one year in the hospital in the beginning of 2004. Already this data indicates a big number of patients who were hospitalized years ago, were chronically ill and for whom the hospital served as an asylum as they did not have a place to go in the community. Under these circumstances it was no surprise that our query on the average stay in the hospital remained unanswered. A little bit less than one half of the diagnoses of the newly admitted patients were schizophrenia. The hospital admitted also a significant number of drug addicts (one fourth of the newly hospitalized). The hospital employed six doctors (two psychiatrists and four neuro-psychiatrists), 40 nurses and 20 orderlies. It also employed administrative and support staff. There were no psychologists and specialists on other types of therapy (occupational, art etc). 2.3.2. Types of wards There were ten wards in the Negrorci Neuro-Psychiatric Hospital. They included: An acute admission and diagnostic ward for men; An acute admission and diagnostic ward for women; Two chronic wards for men; Two chronic wards for women; A ward for men with developmental disabilities and epilepsy; A ward for women with developmental disabilities and epilepsy; Two wards for neurotic disorders and drug dependencies. The average number of patients in each ward was 20-25. Most of the wards were located in separate buildings on the territory of the hospital and were isolated from each other. 2.3.3. Admission to the hospital As in the other mental health institutions in Macedonia admission to the Negorci Neuro-Psychiatric Hospital was seriously flawed, especially in the case of involuntary commitment. The family or, as the Director stated “just a group of citizens”, can turn to the Municipal Center for Social Work in a case of a person who creates trouble in the family or in the community or is dangerous for him/herself. The center would assess the need of placement in a hospital. In case of a positive assessment and if the person agrees to be treated in the hospital voluntarily he/she will be brought to the hospital or will be sent there on his own. If the person does not want to be treated, then the center calls the police and he/she is brought to the hospital by police, as the Director explained, often with handcuffs. The patient is immediately assessed by a collegium of doctors and diagnosed. Then one of the doctors writes a notification to the district court in Gevgelija within 48 hours and the court is obliged to visit the hospital after the admission to pass a judgment on the involuntary hospitalization. This however does not happen in Negorci, just as in most of the other mental health institutions in Macedonia. The criminal commitment, although with more guaranties during the initial placement, was also seriously flawed. The IHF delegation saw several patients who were committed to the hospital in the context of criminal procedures but their situation was not reassessed subsequently and some of them, according to the Director, did not exhibit any sign of mental illness and thus their hospitalization was not justified. Of great concern for the delegation was the case of V. P. who had spent 11 years in the hospital. He had developed schizophrenia and had murdered his mother. This happened accidentally on his way out of their flat, after a quarrel when he pushed her on the stairs. She fell, hit herself and died soon afterwards. The court found P. criminally irresponsible because of insanity and imposed a measure - compulsory treatment. During the last several years the doctors from the hospital had sent several times proposals to the court stating that he was not in need of active treatment any more because of remission but each time the court had confirmed this measure. The last time when a release was proposed the court invited an external expert whose conclusion was that P. should not be released. One of his arguments was that there was no evidence that he would take regularly his medicines, because the last time he had spent 20 days at home, in August 2003, he did not do that and his condition worsened. In addition, the expert interviewed his brother and his brother’s family and they did not seem willing to take care of P. and to allow him to live in their house. P. did not have a flat of his own. The Director explained that they wrote applications to the court only in cases of persons who were hospitalized involuntarily under the civil procedure for the first time and not for the subsequent hospitalizations of the same persons, no matter whether they were voluntary or involuntary. Thus, under the circumstances he had difficulties assessing how many were the involuntary patients in his hospital. At the end he stated that they would probably be approximately 90% of all patients. According to the Director after the admission the doctors explained to the patients their condition and what therapy they need. Then they ask them to sign a form declaring their consent to be treated. If the patients arrive with their legal representative in the hospital the doctors take the consent of the representatives. The form offered to the legal representative read as follows: ”On.......(date) .....(.the name of the person to be treated) has been admitted to the hospital accompanied by (name of the relative or the policemen) and they agreed to leave him/her to be treated. Signature of the relative.)“ The delegation saw such a document for T. B. whose mother left him in the hospital on 29.02.2004 and gave consent for treatment on his behalf. There was also such a document from 22 March 2003 for T. K. The other record that the delegation saw was a notebook from one of the wards on the first page of which it was written “the patient has been acquainted with his condition, the types of therapies possible in this condition, the risks of the therapy etc. He agrees to be treated according to the proposed therapy.” Then there were the names of patients, the dates of their admissions and their signatures. But some of the patients were admitted in 1978, others in 1996, others in 2002 (the records were not in chronological order) and the doctors were not able to explain when exactly they introduced this notebook – so it was obvious that they just decided to have a book like that and they went to all patients available in their ward and made them sign the book. 2.3.4. Living conditions and hygiene The IHF delegation visited most of the wards and could move freely inside them. The acute admission and diagnostic ward for men had rather spartan conditions. The delegation saw a room of 10 sq. m. with three patients inside. There were bars on the windows and only one cabinet for placement of personal belongings. Another room that the delegation saw was 20 sq. m. with eight beds but only five patients. There were three cabinets for personal belongings. The rooms were bare and impersonal. The dining room only had one table and a bench. The hygiene in the rooms and in the toilet was mediocre. The situation was similar in the women’s acute admission and diagnostic ward with a little bit more personalized spaces. There was a day room there with a TV set. The patients in both wards were just sitting in their rooms, not engaged in any meaningful activity. Patients were watched closely by the staff although some could go out of the ward on their own. The ward for men with developmental disabilities and epilepsy was a real cause of concern. It was overcrowded, too dark, infested with flies and smelled of urine. Rooms and toilet facilities were in a very bad state of repair. There were faeces on the floor of several of the rooms under the beds. The patients were lying in their beds in their dirty and ragged clothes or staying in the corridor, not doing anything. The windows of the rooms were barred. One of the rooms visited by the IHF delegation was 24 sq. m. with eight beds. It had tiles on the floor, although there was little benefit of this as they were covered with a lot of dirt that was apparently not cleaned since long time. Another room was 16 sq. m. with four beds and a bared window. There were no cabinets and the entire environment was very impersonal. The floor was dirty and a horrible smell filled the air. The beds were covered with sheets, but they were very dirty. The patients in this ward were locked all the day and apparently the attention they were receiving was minimal. These were all people with severe developmental disabilities that were institutionalized since long time ago and were likely to spend the rest of their lives in institutions. By all standards the living conditions they were placed in the ward amounted to inhuman treatment. The chronic wards, some of which the delegation saw, looked a bit better compared to the ward for persons with developmental disabilities in terms of material conditions. Nevertheless, there too the hygiene in the patients’ rooms and in the toilets was at a rather low level. In some buildings plaster was falling down and the floors were dirty. Some of the mattresses were very thin because of long usage, so the patients could feel, while lying in the bed, the bed construction. The maintenance was limited to the basics. In almost none of the bathrooms one could see necessities for maintenance of personal hygiene, soaps, towels. Several doors of toilettes were taken away, and/or leaned against a wall. Not only that there was no privacy for patients, but one could also get easily hurt, if the heavy doors fell down. Every bathroom/toilette was smelly, and the smell spread throughout the ward. The wards for neurotic disorders and drug dependencies were exceptions. The living conditions there were much better than in the rest of the hospital with more personalized environment, sufficient places for placement of personal belongings and higher level of hygiene. The rooms were tidy and well maintained as were the bathrooms. 2.3.5. Food The IHF delegation did not receive information on the daily food allowance. It could not see how a meal in the hospital looked like. The patients interviewed did not complain of the food. Some patients could receive food from their relatives. Others could buy from neighboring shops. 2.3.6. Therapy Pharmacotherapy was the major form of treatment in the hospital. The Director mentioned also occupational therapy and group therapy but in lack of qualified and permanently engaged personnel these apparently were marginal activities. The type of drugs used in the hospital depended very much on what was available through the 'positive list'.[ Positive list is the list of drugs, which can be obtained via doctor’s receipt and their price is covered by health insurance.] At the time of the visit this list included only old type neuropleptics, such as Hlorpromazine and Haloperidol. The Director explained that some of the atypical neuropelptics were expected to be included in the new 'positive list' that was in preparation and was expected to enter into force since the autumn of 2004. Some patients could bring into the hospital drugs that were prescribed during their previous treatment or were bought by the relatives while they were in the hospital. Thus, the delegation saw a patient who used Rispolept (Risperidone) bought to him by his relatives. Barbiturates and benzodiazepines were also in the 'positive list' and were widely used. The list included also some anti-depressants, including SSRI and tricyclic anti-depressants, but there were not many such conditions in the Negorci hospital. In the chronic ward the delegation saw many patients exhibiting signs of extrapyramidal side effects, a result of improper dosing of neuroleptics, in a number of patients who had spent many years in the hospital. The Director said that this was 'normal' and that the proper treatment of the extrapyramidal conditions was 'more neuroleptics'. One of the methods of treatment the hospital applied in cases of chronic endogenous depression and other conditions was the electro convulsive therapy (ECT). In Negorci it is applied in its unmodified form, i.e. without anaesthesia and muscle relaxants. When the Director heard the concerns of the team, he said that he did not see anything wrong with the application of the unmodified ECT and that they had applied it in this form for many years and never had any accidents. The ECT was applied in a separate room in one of the wards, which the delegation saw. The Director offered the team the consent form for application of ECT. It became clear that the form was signed not by the patient on whom ECT is applied but by the parent or the guardian. The form did not contain any information on the nature of this treatment method. The parent/guardian just had to sign that he/she was 'acquainted with the need for the application of the treatment and with its nature'. When asked about informed consent for treatment the Director said that they usually seek such consent from the relatives or guardians, if the patient is under guardianship. No special forms were filled. A number of patients who were interviewed by the delegation understood the reason why they were in a psychiatric hospital but very few knew anything about the effects of the medication they were taking. 2.3.7. Seclusion and restraint There were no seclusion rooms in the hospital. Some of the patients, mostly from the acute admission and diagnostic ward, were being restrained with belts in the beds of their rooms. This happened in front of the other patients. According to the Director this procedure was applied under the order and the supervision of a doctor. He said that restraint was applied always by 2-3 staff members. They put the patient in the bed and tie to the frames of the bed with belts his two legs and two arms. Then a nurse administers the injection. The restraint lasts for no more than two hours. The cases of restraint were registered in the therapeutic lists of the patients. The hospital kept a book where the cases of restraint were registered. There were instructions given on the front page of this book on how to apply restraint. The instructions said that the doctor who applied the restraint had to write down at what time and for how long it was applied, how he did that and the names of the patient. The instructions said that the doctor who applied the restraint had to have medicines to apply, to try to make the person lie on the bed voluntarily, to try to explain to him the other possible treatments at that moment, to talk to the patient all the time, not to leave the patient without supervision while fixed, to release the patient after two hours at the most. There were four entries in this book – three from 7, 8, 9 May 2002 for T. A., who was fixed to prevent him pulling the threads of his operation spot. The fourth entry was from 10 May 2002 and was for another person. The staff claimed that they apply restraint but record the cases in separate books kept in the wards. There were no such books however in the two wards in which the delegation asked to see them. When asked about the legal basis of seclusion or restraint the Director explained that there was no such regulation in Macedonia but that there were some in preparation. 2.3.8. Inspection The Neuro-Psychiatric Hospital in Negorci did not receive much attention from the Macedonian authorities. Only officials from the Ministry of Health visited the hospital from time to time. The IHF delegation did not see any documents from these inspections. 2.3.9. Other human rights problems One patient in the acute admission and diagnostic ward for men complained that he was forced by an orderly to take his pills and that he was beaten up by him recently. The patient had an eye haematoma of a recent origin, which he said was a result of a hit in the eye. Some patients could walk out in the yard and some even went out of the hospital to the neighboring villages and towns, but others, e.g. those in the wards with developmental disabilities and epilepsy, spent their time locked in their wards with very few opportunities of activities and entertainment. Such a situation is not only not conducive to creating of an appropriate therapeutic environment but amounts to inhuman treatment. |
Íàøà êíîïêà  |
|