[The role of patient competence in the new Dutch statute concerning involuntary treatment in psychiatry]. / De rol van wilsbekwaamheid in de Wet verplichte geestelijke gezondheidszorg.

BACKGROUND: In the new Compulsory Mental Health Care Act (Wvggz), patient competence has a more central position. AIM: To describe the new position of patient competence in the Wvggz and to reflect on related moral questions. METHOD: Discussion of relevant legal texts and publications. RESULTS: In case of incompetency of a patient, a surrogate decision-maker has to attempt what decision the patient would make if he or she were competent. A new element in the Wvggz is that grandparents and grandchildren can also act as surrogate decision-makers. A competency judgment is mandatory in every decision on involuntary treatment, with the exception of involuntarily commitment. Competent refusal of care has to be respected, unless the patient is in a life threatening situation or there is a risk of other people getting harmed. CONCLUSION: The question is whether the changed position of patient competence in the new law will contribute to the aim of maintaining and enhancing patients' autonomy. Due care in competency judgments is complex and remains important.

[Does less seclusion create a safer environment? An attempt to map the concept of 'feeling safe']. / Minder separeren, veiligheid creëren; het concept 'veiligheidsgevoel' in beeld gebracht.

BACKGROUND: The degree of restraint imposed by a psychiatrist seems to be influenced by the safety of the team. So far, there have been few attempts to map the concept of 'feeling safe'.
AIM: To analyse, define and quantify the concept of 'feeling safe'.
METHOD: Concept mapping involves combining, in a structured way, qualitative (item collection) and quantitative methods (multi-dimensional scaling and hierarchical clusteranalysis) with the knowledge of professionals from psychiatric practice (N=24), first on an individual basis and then as a group (N=8).
RESULTS: The participants generated and prioritised a total of 97 different items. These were then divided into six clusters: organisational structure, professionalism of team members, increased expertise, marginal conditions, internal and external features of the hospital building, views on mental health care and policy. Group members gave almost equal priority to the clusters, but they assigned different degrees of importance to separate items (ranging from 4.63 to 2.38 on a five-point scale).
CONCLUSION: Concept mapping is an adequate method of defining the concept of 'feeling safe'. Professionalism of the team and qualities such as openness and ability to communicate, expertise and trusting one's colleagues and having an adequate alarm system available are all important factors that help to make employees 'feel safe' in their respective departments.

[Resolution of a treatment impasse by combining two Dutch laws regarding a patient with paranoid thoughts and a testicular cancer]. / Behandelimpasse bij een patiënt met paranoïde denkbeelden en een testis--carcinoom doorbroken door gecombi-neerde inzet WGBO én Wet Bopz.

Doctors dealing with patients who simultaneously have both psychiatric and somatic disorders often find themselves 'trapped' between two Dutch laws, the WBGO (the Law on the Medical Contract) and the Bopz (Law on Compulsory Admission to Psychiatric Hospitals). In order to illustrate a typical situation we present a case-study concerning a 50-year-old male with a probable seminoma testis and paranoid thoughts arising from an autistic disorder. The patient had refused the investigations and treatment that were considered necessary. His compulsory attendance at the Court of Law and the adoption, by the doctors, of a multidisciplinary approach led to a successful outcome and patient satisfaction. We hope that the new Involuntary Mental Health Care Act (WvGGZ) will bridge the current gap between WGBO and the Bopz.

[Determinants of seclusion in a psychiatric institution: a naturalistic and exploratory study]. / De determinanten van separaties in een psychiatrische instelling: een naturalistisch en exploratief onderzoek.

BACKGROUND: Seclusion of a psychiatric patient is a multifactorial process in which patient, staff and ward variables all play a role. So far, few studies have investigated to what extent these variables in combination can be the determinants of seclusion. AIM: To investigate, in a multivariate study, what influence certain patient, staff and ward variables had on the decision to seclude a psychiatric patient and to use the findings to support specific interventions which could reduce the total number of seclusions in our institution. METHOD: We based our study on 78 secluded patients and 96 similar control-patients (not secluded at that time) and we collected data from these patients with regard to some quantified patient, staff and ward variables. In this retrospective cross-sectional study we performed a multivariate logistic regression analysis on the data. This enabled us to study associative links but not causal links. RESULTS: Seclusion was found to be a multifactorial process which revealed significant associations with several patients variables (nosie-variables irritability and motor retardation) and one staff variable (subjective feeling of safety among nursing staff on the day of the patient's seclusion). We also found many more non-significant associations. CONCLUSION: Interventions that might reduce the number of seclusions (in our institution) should perhaps be directed towards the irritability and motor retardation of the patient and towards feelings of safety among the nursing staff.

[Assessment of decision-making competence]. / Wilsbekwaamheid beoordelen.

Care providers are frequently confronted with complicated questions about decision-making competence. This article offers tools to help them to deal with those questions. We also look closely at the underlying legal aspects of competence, how and when competence should be assessed, who is responsible for this assessment and which tools are available for this process.

[In-house apartments: an attempt to handle complex chronic psychiatric disorders]. / Inleunappartementen: een poging om complexe chronische psychiatrische problematiek hanteerbaar te maken.

SUMMARY: A ward of the ggnet, a mental health centre in Apeldoorn, has developed a unique way of coping with often complex and severe problems of patients with chronic psychiatric disorders. It has created a one-person facility, called an in-house apartment. The in-house apartments have been evaluated and appear to be an effective way of dealing with some patients with complex chronic psychiatric disorders - specific types of psychiatric disorders and personality problems.