Claude Ruey State Councillor

Thank you to welcome me today. Madam the president, I came without fear because, as you said, what is interesting in the sanitary field is that it necessitates discussion, the psychiatric field specifically, necessitate consultation, confrontation of ideas without any doubt, but not of people. So I came today with a totally serene soul to exchange some talks with you, to talk about restraint measures, forced treatment, patients' rights, all are important themes to be dealt with precaution because they touch freedom and, more often, people's dignity. The respect of human dignity, isn't only the privilege of the patient, it has to be said, but it is also the hospital's staff which is concerned, and I think your action goes in this direction and so has to go our common action. So it is under this double light of the patient's human dignity and of the hospital staff that has to be approached the delicate themes that are ours today. I do it with pleasure, because I think they are very important themes. They are fundamental themes. They guide the action which I conduct in sanitary matters and that I will continue to conduct indirectly as a member of the college, so I will still have my word to say at the level of the governmental sanitary politic. I would like to dissipate a misunderstanding. On the contrary of what may have been said, or even published on the internet, to this day no definitive law project were submitted to me so I haven't accepted anything yet concerning today's themes. So today I will only talk about the general problematic which is in the back ground of this subject, the project itself hasn't come to an end yet. In the heart of our legislation, there is the patient's right to decide whether he wants to be the object of a treatment. It is one of the fundamental value people think is important in this country. The patient has to give his agreement, it is the general rule. Of course you know that there are exceptions: the deprivation of liberty in order to give assistance is stated in the Civil law and the Federal Court's jurisprudence admits restraint measures in a wide sense and forced treatment provided they have a clear base in the legislation of the canton, there is a dominating public interest and these measures are proportionate. Besides, these measures shouldn't reach the essence of personal liberty. Recently in a few cantons new laws content such measures, it is the case in Bale-Ville, Appenzell, Lucerne, and Zurich. As you can see, if liberty is the general principle, the legislation allows limited exceptions to the patient's liberty. In fact, in this field, practices have evolved a lot these last years in the direction of dialogue with the patient and respect. Remember that it hasn't been for a long time that the law allows the patient to see his file. It's has been for less than 20 years that the patient has access to his file, to the knowledge of his file, to the possibility of obtaining information that before were not given. So the evolution goes in the direction of dialogue, respect of the patient. Does it means that everything is perfect? Does it means that the medical teams face adequately all situations? You do know very well that this is not the case. In this field it is important to stay modest, to stay particularly vigilant and regularly to question one self and to correct all that can be. You may have noted that for a little more than a year, the Insurance and Social Foresight Service, the Service I direct inside the Public Health Department, has particularly stressed for a greater respect and for a greater observation of the practices of medico-social establishments. Thanks, it has to be said, to the contacts we had with patients' associations, with associations such as yours, which have cast light on bad practices which were not sufficiently supervised. The politic we want to follow intend to protect the patient and the hospital's staff. On the psychiatric level it also has to be noted that since 1993 there have been developments in the role of ethical commissions in psychiatric medicine, and also in somatic medicine. Their role is more and more important. In psychiatry, these last years, diverse dispositions have been taken to make the hospital's staff to cast a fresh eye on the questions asked over restraint measures and more widely on the patient-hospital's staff relations. If I take the example of Cery, an agreement has been reached between the direction of the canton's hospices and the direction of the university department of adult psychiatry, the following measures have been successively realised: In 1994, analyse of the number and of the causes of situations of violence in the institution. In 1995, realisation of written directives concerning restraint measures. Since 1996, regular courses of medical ethics in psychiatry. Since 1997, regular courses of violence management and creation of a post of mediator. And since the beginning of this year, regular enquiries on the satisfaction of patients. It is to be noted that the GRAAP took part in the realisation of these enquiries. However, despite these measures, which don't change overnight our comprehension of problems and our way of actin, on the legal level, the Public Health law doesn't expressly treat with restraint measures and forced treatment, it doesn't clarify the exceptional situations which could lead the hospital staff not to respect the patients will. There is a gap. We have taken note of it. It is why around a year ago, I gave M. Toriel, director of the Service of the Hospices of the canton, the mission to direct a little work group to study the question, to propose legal and organisational measures in order to improve the patients protection and to clarify the rights and obligations of the hospitals staff. Patients and hospitals staff have both to be taken into account. At that time I proposed the GRAAP to associate, which it did before they left. I had the opportunity to talk about it to Mrs Pont, it is her right, it is also her responsibility. I think that when we met a few weeks ago a certain number of misunderstandings were dissipated. This work group, I say it with a smile but firmly, isn't aiming, I allow myself to tell you, as it is written today in the «Temps» , under your signature, «to legalise purely and simply forced treatments and restraint measures in hospitals, medico-social establishments and prisons». I believe that here too it is necessary to dissipate this misunderstanding and I say it firmly. It is not because in a work group they are people member of the public function, that it means that those people have only one goal: the defence of the administration and the legalisation purely and simply of the forced treatment. That would be an injure to the representatives of the public function. I believe that it is not because we are public function members that we are not able to think, I would even say the contrary. The work group is composed of a lawyer; the doctor of the canton, about whom it can't be said that he is a traditionalist civil servant; Mr Gaulaz who deals with those questions in the service of the public Health; Mr and Mrs Pont who successively took part and then left the group; somebody of the Fondation of Nant, Mr Panchaud, nurse; the doctor Bruno Gravier, doctor psychiatrist, it is right, he is responsible of the penitentiary psychiatric service, but he is first of all a doctor; Mr Favre; Mr Pierren, director of the penitentiary establishments of the «Plaine de l'Orbe»; and finally of Mr Toriel. This group gathered ten times between May 1997 and February 1998. Two supplementary meetings allowed to consult, on the base of a pre-project (not a project, and I haven't seen it yet) representatives of psychiatry and of the Association of the Canton of Vaud medicosocial establishments. These representatives were Mr Borgeat, Mr Camus, doctor Gasser, Mr Laubscher who is director of the HUG Belle-Idée in Geneva, doctor Jo Montandon from the hospital of Bellevue in Yverdon , doctor Edouard Perrot of Pranggins, Mr Demont president of the ethical council of the AVDEMS, Mrs Genevieve Villard nurse at the Fondation de l'Orme, Mr Marc Vuilleumier director of the Fondation de l'Orme and member of the ethical council of the AVDEMS. So as you can see, a wide range of people were represented, wider than what people thought, and the very rich discussion which took place between those persons allowed to clarify and to modify sensibly the pre-project. It is in deed the goal of hearing contradictory points of view, to take into account aspects that could have escaped the first writers. I add that the work group has benefit since October 1997 from an observer from Geneva Mr Henri Pernet who is the general secretary of Belle-Idée in Geneva and who brought his experience of the legislation and of the practices in Geneva. It is a way to open to the outside, to make our thinking richer, it is also a way to see that the co-operation Vaud-Geneva can be positive. The exchange that comes out of it is useful for both sides. Geneva may inspire itself on its turn from our own thinking to modify or to complete its legal system. Today the report of the group is being finished and will be submitted in the next weeks, because I intend to finish this project under my authority, I am saying this for my collaborator Mr Toriel, present here. The mandate has been longer and more complex than it was first thought, we were supposed to finish at the end of February. In deed during its work the work group had to widen its field in order to also cover different themes, for example: patients' rights, anticipated directives, information of the patient, his right of appeal. In fact we didn't want to propose a legal revision valid only for psychiatry but we wanted to create a system which covers any similar situations - and they are numerous. In somatic medicine, in the medicosocial establishments, penitentiary establishments, a global vision is necessary but at the same time it is necessary to take into account the different situation of each of these institutions. Many fundamental questions are in the heart of the work I asked this work group to undertake. They are real society's problems that we will have to solve together. In which circumstances can we treat a patient against his will? In which circumstances can we use restraint measures against the will of the patient, that is to say limit the patient's liberty of movement in the institution, put him in an isolation room or tie him down? The federal law created dispositions on liberty deprivation in order to give assistance. How are these dispositions to be interpreted when at the same time it is necessary to respect as well as possible the patients rights recognised by the national and international legislation. The answers to these questions aren't obvious, Madam, Sir, it isn't for nothing that you talk about it. In this field, the hospital's staff sometimes have to face two different pressures: the will to save, to protect a patient and the will to respect his will. Think of a person who wants to commit suicide. Think of an anorexic person who endanger their life if he isn't taken care of. Some will say that in these cases the forced treatment is adequate to avoid the patient's death, some on the contrary will think that in such situations it is necessary to respect the patient's will even if it means taking the risk that he may die if he refuses the treatment. Serious question. As far as I can think, I reckon that the hospital's staff has to do any thing to convince the patient of the adequacy of the treatment. Think of the person in crises who mutilate herself. Think of the person who act violently without control. Think of a patient extremely agitated who lost the control of his actions, delirium tremens, brain traumatism for example. Think of the patient half unconscious who may tear off his probe or his drip. Think of the weak or agitated elderly who may fall of his bed or chair. To face these situations it can't be excluded that restraint measures could be an adequate mean. So we can't answer, it's black or white. Interrogated on this subject, the Ethical Commission of psychiatry proposed, in July 1997, not to exclude restraint measures with strap, which is, according to it, acceptable in situations of violence, I quote: «with important reserves, and with diverse adjustments coming from the principle of proportionality and of the respect of the patient's dignity.» The Ethical Commission explains in this way, I quote: «obtaining a sufficient sedation through medicine necessitate quite often doses that can cause risks on the biological level and so some patients prefer an immobilisation by strap instead of medicine they don't know and fear the effects.» Once again I must underline that this is to be discussed, and that it will be. At last, when a member of the hospital's staff is facing a dangerous patient, he must also protect the other patients, but he has also the right to protect himself. But I stress that restraint measures, which can't be totally excluded have to be taken with the respect of the patient. This later has to be repeatedly informed, about the motive and the nature of the restraint measures, which have to be avoided as much as possible. During the measure, the patient has to be specially surrounded, reassured, it is necessary to dialogue with him as much as possible. The medical staff shouldn't oppose violence to violence. particular attention has to be given to the need of the patient, notably in comfort and hygiene matters. This is one side of the problem. On the other side, restraint measures that would be used to punish a patient must be excluded. It is the same thing about restraint measures that would aim to immobilise a patient so that he doesn't need to be taken care of, by instance by measure of comfort or of convenience. This is totally unacceptable. I know that some people claim that a link can be made between the number of staff in an institution and its way of practising restraint measures but when the Ethical Commission of psychiatry compared eight clinics, it couldn't draw any conclusion on this subject. The problem doesn't stand at this level, it is more at the level of formation. And I state that the efforts in the formation field undertook in psychiatry these last years show results and that measures such as restraint measures are luckily more and more rare in our canton. But I don't want to be too positive. Set backs are still possible and are sometimes stated. They must be repressed. It is for this reason that a commission for examination of complaints has been created this year for medico-social establishments; it is for this reason that a system of appeal will be present in the proposed law on public health, against violation of the person's rights. The appeal authority that we want to create will have to have four qualities to be efficient: the authority has to be independent; it will have to be specialised enough to be a good judge in the matter; it must be able to give a ruling rapidly; and it must be free for the plaintiff. The questions which are asked are far from being easy and today I am not bringing you ready made answers. I am bringing you my interrogations, our interrogations, to share them. The work of the work group is about to be achieved, but the dialogue won't be finished at this time, because on the basis of this thinking we are going to undertake a wide consultation, to which you will be of course associated because the report that will be submitted to the State Council will be addressed to all the concerned associations and institutions and even to the whole population because it's published in the «Newspaper of officials information» in order to able any body who is interested in the subject to give us his point of view. So the position of the State Council will be taken in good conditions, that is to say with the conviction to act in the interest of the patients, their friends and families as well as in the interest of the hospitals' staff. So I hope that we will be able to end up with a revision of the law on public health really useful allowing a true social and sanitary improvement, this is anyway the objective that we assigned ourselves. It is necessary in these fields to have a real rich and deep debate in the society. With a congress as today's, the GRAAP judiciously participate in this debate. I said it before, we have to debate head to head. I above all need to listen because the political responsible that I am take strategic decisions. I learn about what comes from the field, from the specialists. You are a part of the specialists, there are others that are in institutions and it is in this way that arbitration can be made and that ethical choices can be made. This ethical choice that is in your petition, I can say I share it totally with you, and I am even able to sign it, even if, on such a delicate themes there is always more to learn, to understand, for patients, for medical teams and for our society.