MODULE 2: CRISIS PLANNING AND PATIENT CHOICE
There are a number of ways to think about how we communicate our mental well-being and there might be a number of reasons why someone needs to use mental health services. Getting to understand and know people who use services in an individualised way can be hugely beneficial to ensure they receive the right care at the right time. Part of this process is to understand and see the world through their eyes. This can be particularly important for people who use services when they experience distress.
In this module we aim to demonstrate some good practice principles in how services structure a discussion on care planning, crisis care planning and advance choice documents. This includes:
- Exploring well-being, values and identity
- Describing and exploring distress, crisis or relapse
- Exploring who might support the person when distressed and what they can do
- Thinking about risk and safety
- Agreeing who to share the informaton with and when to review
GETTING TO KNOW THE PEOPLE WE SUPPORT
As a starting point, its important to get to know the people who use our services.
We may be able to review medical notes. But it is helpful to hear this from the person themselves. If we have permission, it might be helpful to ask a carer or significant other. Getting to understand people who use services includes what is important to them and what mental health and well-being means to them; and what promotes their well-being e.g. family, spirituality, exercise, sources of support.
This conversation can be helpful at any point in someone’s care, but probably best done when they feel able to explore these issues. This conversation may include areas such as:
- Their identity and the things they value
- What their interests and goals are
- What a typical day looks like
- Any responsibilities they have
Is this video, you will see a segment of conversation, where the clinician is learning more about the person using services
NOTE ON INVOLVING FAMILIES AND CARERS
Sometimes, the person’s family, carers or significant others are an important source of support and it might be helpful in our care planning and advance choice documents to think about their role. For example, who does the person want to be informed or not informed about their mental health problems? If they are brought to services by a friend or family members, how should services work with this person? For young people, under the age of 18 years old this can be particularly important.
It might be that we can get this information from the person themselves. If we have permission, we might need to ask the carer or significant other themselves. When friends and families are available to support, it is important to consider what type of support they are able to offer as well.
While the involvement of carers is important for some people who use services, it should be acknowledged that not all people have a carer or may not wish family members or persons of significance in their life to be involved in their care. It is important to check with the person what their wishes or preferences are.
EXPLORING DISTRESS
Its important to understand what a person’s experience is like when they are struggling with their mental health, especially where they need support from services or decisions made about their care.
We have used the word “distress” to describe this experience, but it's important to think about the language the person who uses services and their family might use to describe times of distress. Other descriptions might include crisis, relapse, being unwell, feeling mentally unwell. Using the words that make sense to the person is really important.
Alongside this, much like getting to know the person, it is important to explore how they might experience distress.
In the following video a clinician explores with Ali and Joe what being distressed looks like for them
EXPLORING HOW WE SUPPORT
Now that we understand what a distressing experience is like for people, it’s helpful to understand who they might seek help from. This will help clinicians, health professionals and non-clinicians understand who the person considers important in helping them feel safe.
Sometimes the person might not know, so it can also be helpful to review their notes to identify what support they have used. For example, have they used crisis services such as A&E, the Home Treatment Team, Crisis Line or a crisis café? It might also help us understand which family members, friends and communities are important to that person during a time of distress.
As well as understanding what services do, an important part is how they do it. For many people and their families, how they are treated or perceived can have an impact on the decisions that are made.
Alongside the important details about medication and the need for admissions, we can also explore how people are cared for.
When trying to explore this we might want to explore previous experiences of distress, especially where things have gone well and not gone well. Understanding what has not worked, provides an opportunity to change how services respond.
In the following video a clinician explores with Ali and Joe what their experience is when services are not working as well as they would want.
EXPLORING RISK AND SAFETY
At times of distress people can engage in behaviours that are risky towards themselves and others. Not everyone who engages in risky behaviours will want an admission, but it is important to explore the wishes of the person and the options clinical services might consider in those moments.
An important part of our planning and advance choices include understanding the risk, the person’s wishes and how we might support the person to feel safe.
Risky behaviours can be an important part of a person’s experience and communication of distress, so understanding their wishes in response to these events is critical.
As well as understanding the perspectives of the person using services, with their permission, it can also be helpful to hear from carers and significant others about what support they may need to continue being able to offer support.
The following clip is an example of the questions you can ask to get this information. Some of the content and discussion on this clip might be distressing for viewers, as Ali talks about her experience of self-harming and what impact it has on her and partner Joe.
EXPLORING ACCESSING AND REVIEWING ADVANCE CHOICE DOCUMENTS
It will be important when completing an Advance Choice Document that, just like any other care plan, there is agreement on:
- Who needs to see the document
- How they will access it
- How to ensure it is reviewed and kept up to date
The key people who may need to have access to the document in a crisis, and how future access should cater for this, is likely to include:
- The person who use services
- The person who use services' friends/family
- Mental health trust professionals: e.g. community psychiatric nurses, psychiatric liaison nurses, section 12 approved doctors, ward doctors and nurses
- Social care professionals: Approved Mental Health Professional
- Physical health trust professionals: Doctors and nurses in A&E and on medical wards
- Paramedics
- Police
- General practitioners
How access and reviews for Advance Choice Documents take place will evolve as they are likely to become digital documents in the future and used on a variety of computer systems.
When to review the document should be discussed when the document is made. The person who use services may prefer to review to document within a certain time frame. For example, 6 months or 12 months or after significant events, such as an admission or life event.
