2023-06-23 12:38:36
No coercive measure can be implemented once morest a patient in a care program. In the event of damage related to a break in this program, what is the responsibility of the establishment?
Introduced in 2011 with the reform of care without consent (1), the care program (PDS) is a modality of outpatient care under constraint. Designed as an alternative to full hospitalization, the PDS offers patients the opportunity to reintegrate into the community while benefiting from close monitoring. According to the High Authority for Health (2), it is a therapeutic tool whose “The common thread is to enable the person to return to voluntary care as soon as possible, aiming for a therapeutic alliance all along the way. » This device concerned nearly 42,000 patients in 2018 (2). What should the caregiver do if the program breaks?
What is it regarding ?
The PDS intervenes at the end of a complete hospitalization without consent. It can be triggered, at the earliest, at the end of the initial observation period of 72 hours. It takes the form of a written document, drawn up by a psychiatrist from the establishment, and defines the types of care, their periodicity and the places where they are carried out (3). It is established during an individual interview with a view to obtaining the patient’s opinion. At any time, it can be modified and adapted to the patient’s state of health (4) . It should be noted that the PDS does not include indications relating to drug treatments, the nature and manifestations of mental disorders (4). In the event of non-compliance with the PDS likely to lead to clinical deterioration, the psychiatrist can suggest that the patient return to the establishment (4). This reintegration into full hospitalization does not constitute a new care measure without consent, but the continuation of the initial measure, the form of which has been modified. Thus, “medically”, an indication of return to the establishment can be asked and announced to the person. If not, what does the law say?
Modalities of reinstatement
In this context of care without consent, the Public Health Code (5) specifies that“no coercive measure can be implemented with regard to a patient treated in the form [d’un programme de soins] », which poses a recurring difficulty for health professionals. Caregivers are not allowed to enter a person’s home. If the patient refuses to let them in, they have no alternative.
Very often, their reflex is then to solicit the forces of the Order to assist them in their efforts to return to care for the patient, even if this recourse remains debatable on an ethical level. In addition, the police or emergency services can only intervene in certain specific situations. Failure to comply with a care plan is not a criminal offence,
but the situation of danger for the person can legitimize assistance from these services. In practice, a limit often lies in the material possibility: in a given time frame, it is not easy to coordinate to show up at the same time at the person’s home. Furthermore, staffing problems do not facilitate the process.
The key word: traceability
Implicitly, on the legal level, are the issues related to liability. Several actors come into play: the hospital, the psychiatrist and the patient. The patient in the care program remains under the responsibility of the hospital. Without any specific provision, the liability regime is modeled on that of trial discharges, ie compensation of third-party victims by the hospital on the basis of the special risk linked to the methods of care (6).
Therefore, in this context, traceability is the key word. As soon as a patient does not show up for the monthly appointment, it is advisable to contact him, ask him the reasons for his absence and give him a new appointment. Faced with the impossibility of reaching him, or his silence, the trusted person can be contacted. Depending on the situation, home visits may be considered. Similarly, depending on family ties, in compliance with professional secrecy, contacts may be established to inquire regarding the patient’s state of health. Remember that the institution has an obligation of means (and not of results), that is to say that it must do everything possible to try to locate the person, convince him to return to the hospital, and be able justify these steps.
In fine, the care program is a modality of constrained ambulatory care excluding any coercion, i.e., for lawyers, a real Ojni, “unidentified legal object” (7)…
Valériane Dujardin-Lascaux Jurist, EPSM of Flanders
1– Law no. 2011-803 of July 5, 2011.
2– Program of psychiatric care without consent, implementation. HAS, Good practice guide, 2021.
3– Article L.3211-2-3 of the Public Health Code.
4– Article R.3211-1 of the Public Health Code.
5– Article L.3211-2-3-III of the Public Health Code.
6– “Runaway” of a patient hospitalized in psychiatry: what to do? Valériane Dujardin-Lascaux, Mental Health, n° 269, June 2022.
7– The care program: what responsibilities? Valériane Dujardin-Lascaux, Eric Péchillon, L’Information Psychiatrique, Vol 96, n° 3, March 2000.
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