Poročilo Varuha človekovih pravic Republike Slovenije o izvajanju nalog državnega preventivnega mehanizma za leto 2011 Z opozorili bolnišnice se strinjamo. Ustrezen redni pregled fiksiranega (telesno oviranega) pacienta, ki ga izvaja zdravnik vsake štiri ure (ali tudi pogosteje), je nedvomno nujen. Ravno tako je prav, da ta po pregledu pacienta odredi, ali se fiksacija nadaljuje ali prekine. Določbo 29. člena ZDZdr je res mogoče razumeti (zgolj) tako, da je fiksacijo vsake štiri ure treba prekiniti in jo po potrebi ponovno uvesti. Ob tem se postavlja vprašanje, ali je (obvezna) sprostitev telesnega oviranja res vedno najboljša možnost, saj bi lahko pomenila tudi nevarnost za osebje ali za samega pacienta. Pomisleki stroke po prepričanju DPM zahtevajo ponovno presojo zdajšnje zakonske ureditve in morebitno spremembo. Poudarjamo pozitivno prakso PB Begunje, ki svoje znanje in ravnanje pri fiksaciji pacienta poskuša prenesti tudi na druge bolnišnice. Opažajo, da pridejo pacienti iz drugih (splošnih) bolnišnic k njim z odrgninami, kar je očitno posledica privezovanja z rjuhami. Izobraževanja organizirajo za zaposlene v splošnih bolnišnicah in v domovih za starejše, da bi tudi tam znali pravilno uporabljali fiksacijske metode. Ob tem znova izpostavljamo potrebo, da se uporaba posebnih varovalnih ukrepov zakonsko uredi tudi v primerih, ki jih ne določa ZDZdr, torej zunaj psihiatričnih in socialnih zavodov. 40 Implementation of the Duties and Powers of the National Preventive Mechanism in 2011 We agree with the hospital’s warnings. Adequate regular monitoring of a physically restrained patient performed by a doctor every four hours (or more often) is undoubtedly necessary. It is also correct that, after checking the patient, the doctor orders the restraint to be continued or discontinued. The provision of Article 29 of ZDZdr may be understood (only) as the obligatory discontinuation of restraint every four hours and repeated implementation of it if necessary. This raises the question of whether the (obligatory) discontinuation of physical restraint is the best option, as it can present a danger to the personnel or the patient. According to the DPM, professional considerations require a reassessment of the current regulation and potential amendment. We emphasise the positive practice in PB Begunje, which tries to transfer its knowledge and conduct in restraining patients to other hospitals. They notice that patients from other (general) hospitals come to them with abrasions, which is obviously a consequence of being tied with sheets. They organise training for employees from general hospitals and nursing homes to teach them how to use restraint methods correctly. Once again, we stress the need to regulate the use of special protection measures in cases not specified in ZDZdr, i.e. outside psychiatric and social institutions. Ob pregledu dokumentacije konkretnega primera fiksacije smo ugotovili, da je ta skupaj trajala 17 ur in pol. Obveščena sta bila direktor PB Begunje in najbližja oseba (obrazec Obvestilo o posebnem varovalnem ukrepu). Ni pa bil obveščen zastopnik po ZDZdr, po pojasnilih bolnišnice zato, ker se pacient ni bil sposoben izreči, katerega zastopnika želi. V drugem primeru so bili o izvedenem PVU obveščeni direktor, najbližja oseba in zastopnik. Predstavniki PB Begunje so pojasnili, da o fiksaciji, ki s prekinitvami na štiri ure traja dalj časa, obveščajo osebe po ZDZdr vsakih 12 ur. Že ob samem obisku smo opozorili, da bi bilo obveščanje treba izvajati na štiri ure, saj se dejansko ukrep vsake štiri ure izvede na novo. To opozorilo (kljub pomislekom o smiselnosti ponovne uvedbe vsake štiri ure, ki smo jih navedli zgoraj), smo ponovili tudi v poročilu DPM. Odziva bolnišnice nismo prejeli. In reviewing the documentation of a particular case of restraint, we found it had lasted a total of seventeen and a half hours. The manager of PB Begunje and the next of kin were notified (the Notification on a Special Protection Measure form). However, the representative under ZDZdr was not notified; according to the hospital’s explanation, the patient was unable to choose a representative. In another case, the manager, the next of kin and the representative were notified. The representatives of PB Begunje explained that persons under ZDZdr are notified every 12 hours of long-lasting restraint, with interruptions every four hours. During the visit, we pointed out that notification should have been performed every four hours, as the measure is implemented anew every four hours. This warning (despite the consideration of the rationality of the repeated implementation every four hours stated above) was repeated again in the DPM report. The hospital has not responded. V PB Ormož se med posebnimi varovalnimi ukrepi po ZDZdr uporablja telesno oviranje s pasovi segufix. Po zagotovilih direktorice se največkrat uporabi samo trebušni pas, okončine naj bi fiksirali le izjemoma. In PB Ormož, physical restraint with segufix belts is used among the special protection measures under ZDZdr. According to the manager, the abdominal belt alone is used most commonly, and the extremities are restrained only in extreme cases. V ženskem oddelku pod posebnim nadzorom PB Ormož fiksirano pacientko namestijo v enoposteljno sobo, če je takih pacientk več hkrati, pa se za njihovo namestitev uporabi sedemposteljna soba. Pri tem nadzor nad fiksacijo izvajajo medicinske sestre, ki med gibanjem po oddelku (po)gledajo tudi skozi takrat stalno odprta vrata. Na moškem sprejemnem oddelku se fiksacija izvaja na postelji pacienta, nadzor pa izvaja sobna sestra. In the female secure ward of PB Ormož, the restrained patient is accommodated in a singlebed room; if there are more patients, a seven-bed room is used to accommodate them. Restraint is monitored by nurses who look through the open door of the room while walking around the ward. In the male reception ward, restraint is carried out on the patient’s bed and monitored by a nurse. Poudarjamo, da nadzor fiksiranega pacienta ob stalno odprtih vratih ni najboljša rešitev, predvsem zato, ker fiksiranega pacienta lahko gledajo tudi drugi pacienti, kar gotovo vpliva na njegovo dostojanstvo. Boljša rešitev bi bila uvedba video- in avdionadzora, najboljša pa ureditev sobe za fiksacijo poleg sestrske sobe, kjer bi bil mogoč stalen nadzor pacienta skozi stekleno pregrado. Odziva bolnišnice na te navedbe nismo prejeli. We emphasise that monitoring of a restrained patient while the door is constantly open is not the best solution, particularly since the patient is visible to others, which certainly affects their dignity. It would be better to introduce video- and audio-surveillance, or, optimally, to arrange a restraint room next to the nurses’ room, which would allow constant monitoring of the patient through a glass dividing wall. The hospital has not responded to these statements. Po pojasnilih PB Ormož se PVU izvajajo le krajši čas in tako svojcev o tem večinoma niti ne obveščajo. To naj bi storili le, če je fiksacija daljša od 12 ur. V zvezi s tem smo poudarili, da ZDZdr take prakse ne dopušča. PVU-telesnega oviranja s pasovi ne sme trajati več kot štiri ure (po poteku tega časa zdravnik preveri utemeljenost ponovne uvedbe PVU), najpozneje v 12 urah pa mora zdravnik, ki je ukrep odredil, pisno obvestiti direktorja psihiatrične bolnišnice, najbližjo osebo, odvetnika in zastopnika. Rok 12 ur je za obveščanje določen kot (skrajni) rok, v katerem mora biti obveščanje izvedeno. Obveščanje v zakonu navedenih oseb mora biti torej izvedeno vedno, ko se uprabi PVU prišlo, in ne samo takrat, ko ukrep traja 12 ur ali več. According to the explanations of PB Ormož, PVUs last only for shorter periods, so relatives are usually not even notified. They would be notified only if the restraint lasted more than 12 hours. In this respect, we underlined that this practice is not permitted under ZDZdr. A PVU of physical restraint with belts may not be imposed for more than four hours (after this period, a doctor verifies the justification for a renewal of a PVU), and the ordering doctor must notify the manager of the psychiatric hospital, the next of kin, a lawyer and a representative in writing. The period of 12 hours is specified as the (extreme) deadline for notification. Notification of persons according to the law must always be carried out when a PVU has been implemented and not only when the measure continues for 12 hours or more. Državni preventivni mehanizem v Republiki Sloveniji po Opcijskem protokolu h Konvenciji OZN proti mučenju in drugim krutim, nečloveškim ali poniževalnim kaznim ali ravnanju National Preventive Mechanism in the Republic of Slovenia under the Optional Protocol to the UN Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment 41