1.3 Obiski psihiatričnih bolnišnic 1.3 Visits to psychiatric hospitals Ob obiskih DPM smo velikokrat opazili prekoračitve rokov, kot jih določa ZDZdr za obveščanje sodišča ob sprejemu pacienta, pa tudi rokov za obveščanje določenih oseb, kot je najbližja oseba, in rokov, ki jih zakon določa pri uvedbi in ukinitvi posebnih varovalnih ukrepov (PVU). Pri tem smo v nekaterih primerih lahko ugotovili, da bi bilo ob nekoliko večji skrbnosti bolnišnic možno roke spoštovati. V drugih primerih smo se strinjali, da so določeni roki vsaj glede na sedanje razmere neživljenjski, kar bi bilo treba upoštevati ob pripravi sprememb zakona. Tako so bolnišnice opozarjale na težave pri spoštovanju roka za obveščanje sodišča, saj mora sprejemni zdravnik najkasneje v štirih urah po sprejemu obvestiti direktorja bolnišnice ali z njegove strani pooblaščeno osebo, ta pa mora sodišče nemudoma obvestiti o sprejemu pacienta na oddelek pod posebnim nadzorom brez privolitve. Vendar takšno obveščanje dostikrat ni možno, predvsem pa ne smiselno, če pride do sprejema ob koncu tedna ali pred praznikom, ko na sodiščih ni vzpostavljene dežurne službe za tovrstne primere. Bolnišnice večkrat opozarjajo, da je rok za obveščanje sodišča prekratek, saj pacienti kasneje velikokrat podpišejo soglasje za namestitev in zdravljenje na oddelku pod posebnim nadzorom. Čeprav je nedvomno velikokrat res kasnejše soglasje posledica izboljšanega zdravstvenega stanja pacienta, pa ostaja skrb, da bi prišlo do aktivnega nagovarjanja pacientov k podpisu soglasja. Soglasje, ki ga pacient poda za namestitev na oddelku pod posebnim nadzorom, mora biti izraz njegove prave volje. Torej mora temeljiti na pacientovem zavedanju, da mu bo zdravljenje na tem oddelku koristilo in mu z zadržanjem hkrati zagotavljalo ustrezno varnost. Tako nedvomno obstaja pojasnilna dolžnost sprejemnega psihiatra o tem, kakšno je pacientovo zdravstveno stanje, kakšno zdravljenje bo potrebno in zakaj je smiselno to zdravljenje izvajati na oddelku pod posebnim nadzorom. Vendar pa mora biti pojasnilo pasivno. Aktivno nagovarjanje pacienta k podpisu soglasja, prepričevanje ali celo s tem povezane grožnje lahko namreč v takšni meri posežejo v voljno sfero pacienta, da ta ne more več dati soglasja, ki bi bilo izraz njegove prave volje. Zdravniki v obiskanih bolnišnicah so opozarjali tudi na nezadostno določenost ukinitve telesnega oviranja (vrsta PVU), saj zakon zahteva, da je treba ukrep najkasneje po štirih urah ukiniti, lahko pa ga potem zdravnik znova odredi. Nekatere bolnišnice sedaj to zakonsko omejitev izvajajo tako, da se po štirih urah fizično oviranje ne odstrani, temveč zdravnik zgolj odredi nadaljevanje ukrepa. Kot razlog navajajo (v nekaterih primerih nedvomno utemeljen) pomislek, da je lahko pacient po štirih urah oviranja še vedno nevaren sebi, pa tudi osebju, zaradi česar odstranitev fizičnega oviranja strokovno ni utemeljena. Seveda pa to na drugi strani ne pomeni, da bi telesno oviranje pacienta lahko trajalo tudi dan ali več, kot smo v preteklosti pri posameznih obiskih že ugotovili in je bilo tudi že predmet opozoril DPM. Ob obisku Oddelka za psihiatrijo je leta 2012 CPT opozoril, da uporaba ukrepa telesnega oviranja več dni brez prekinitve, čeprav s kratkimi 15-minutnimi ali krajšimi prekinitvami po štirih urah, ne more biti utemeljena in po mnenju CPT predstavlja grdo ravnanje. V vseh obiskanih bolnišnicah smo ugotovili prakso, ko se praviloma zaradi prostorskih pogojev ali prezasedenosti PVU izvajajo v sobah, v katerih imajo pogled na oviranega pacienta drugi pacienti in obiskovalci, ter celo v sobah, kjer so (redno) nameščeni drugi pacienti. Na nedopustnost takšnega izvajanja ukrepa smo seveda opozorili, posebej pa tudi izpostavili, da je na to ob svojem obisku leta 2012 na Oddelku za psihiatrijo opozoril tudi CPT. Ni namreč primerno, da je nemočen pacient na očeh drugih pacientov, razen če to, kot je opozoril CPT, zahteva sam ali če je znano, da bi bil raje v družbi. Ob tem je treba posebej opozoriti, da ZDZdr zahteva stalen nadzor osebja nad fiksiranim pacientom. Zato praksa, kot smo jo zaznali v posameznih bolnišnicah, ko osebje zgolj občasno izvaja kontrolo nad telesno oviranim pacientom, ni ustrezna in lahko predstavlja nevarnost za zdravje ali celo pacientovo življenje. 82 poročilo o izvajanju nalog DPM v letu 2014 DržavnI preventivnI mehanizEm po Opcijskem protokolu h Konvenciji OZN proti mučenju in drugim krutim, nečloveškim ali poniževalnim kaznim ali ravnanju The NPM also frequently noticed that the deadlines as determined by the ZDZdr for informing the court about the admission of a patient were exceeded and also deadlines for informing certain persons, i.e. family members, and deadlines determined by the act on introduction and termination of the use of special protection measures. It was established in certain cases that with some additional diligence by hospitals the deadlines could be respected. In other cases, we agreed that certain deadlines were unrealistic, at least with regard to the current conditions, which would have to be taken into consideration when drafting amendments to the act. The hospitals complained about difficulties in complying with the deadline for informing the court, since the admitting physician must inform the hospital director or another authorised person about the admission in four hours, who must then immediately inform the court about the admission of a patient to a secure ward without their consent. Such informing is frequently impossible, and particularly not logical if a person is admitted at the weekend or before a holiday when emergency services at courts are not available for such cases. The hospitals frequently warn that the deadline for informing the court is too short, since patients later often sign their consent to admission and treatment in a secure ward. Although, consent is later frequently the result of the patient’s improved medical condition, there is a concern that active persuasion of patients to sign the consent would occur. The consent given by the patient to be admitted to a secure ward must be an expression of the patient’s actual wishes. The consent must thus be based on the patient’s awareness that treatment in this ward would be beneficial and provide them with sufficient safety. The duty of the admitting physician is to explain the patient’s medical condition, the treatment necessary and why is it sensible to implement such treatment in a secure ward. This explanation must be provided passively. Actively convincing a patient to sign the consent, persuasion or even related threats may encroach on the willingness of the patient to such an extent that they are unable to consent in a way that reflects their wishes. The physicians in the visited hospitals also pointed out the insufficient definition of the termination of physical restraint (type of special protection measure), since the act stipulates that a measure must be terminated no later than within four hours and the physician may then order it again. Some hospitals implement this legal restriction by removing the physical restraint after four hours, whereupon the physician merely orders the continuation of this measure. As a reason for this (and in certain cases, undoubtedly founded), they state that patients may still be a danger to themselves or staff after four hours, which is why the removal of the physical restraint is not medically founded. On the other hand, this does not mean that physically restraining a patient could last a day or more, as was established during certain visits in the past and which was the subject of NPM warnings. When visiting the Department of Psychiatry in 2012, the CPT stressed that the use of physical restraint for several days without termination, although with short 15-minute or shorter breaks after four hours could not be justified and constituted ill-treatment according to the CPT. In all the hospitals visited, we discovered that special protection measures were implemented in rooms where other patients and visitors may see the restrained patient, and even in rooms where other patients were (regularly) accommodated due to spatial conditions and overcrowding. We warned about the inadmissibility of these measures and particularly pointed out that the CPT had highlighted the same issue in 2012 when visiting the Department of Psychiatry. It was not suitable for a helpless patient to be visible to other patients unless, as stressed by the CPT, the patient concurs or if it is known that they would rather have company. It must also be emphasised that the ZDZdr requires permanent supervision by staff of restrained patients. As noted in individual hospitals, the practice whereby staff only occasionally monitor physically restrained patients was not suitable and may pose a threat to the patients’ health or even life. IMPLEMENTATION OF THE DUTIES AND POWERS OF THE NPM IN 2014 National Preventive Mechanism under the Optional Protocol to the UN Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment 83