Guide to the Mental Health Act                 APPENDIX 3

Involuntary Admission Procedures and Criteria –
Completing the First Medical Certificate

This appendix reviews involuntary admission requirements and other selected provisions of the Mental Health Act. A copy of the Medical Certificate (Form 4) which physicians complete for an involuntary admission is in Appendix 16.

Appendix 17 provides a checklist to ensure the Medical Certificate is accurately completed.

1.0 Involuntary Admission

In order to be involuntarily admitted to a designated facility, a person with mental illness must meet all the criteria for involuntary admission (see section 6.0). Medical examinations for the purpose of involuntary admission must be in accordance with the Mental Health Act and principles of good medical practice.

2.0 Involuntary Admission Procedures

A person with mental illness can be involuntarily admitted to a designated facility on the basis of a medical examination and completion of one Medical Certificate (Form 4) by a fully licensed physician. The Medical Certificate based on the medical examination completed within 14 days before admission is valid for up to 48 hours from the time of admission which must be recorded on the patient’s clinical record.

3.0 Timing of the Examination and Certificate

Ordinarily, the physician would complete the certificate at the time of the medical examination. However, it is possible to do an examination and to complete a certificate up to 14 days prior to admission. This means, for example, a physician who examined someone 10 days ago, and who receives information later that the person is now suicidal but refuses to see a physician, could write a Medical Certificate today without re-examining the person. In this case, the certificate would have to be acted on within four days -- a maximum of 14 days after the initial examination.

4.0 Language on the Medical Certificate

Specific and plain language descriptions are helpful in summarizing the physician’s opinion. Since the forms are legal documents, legible printing or writing is important.

5.0 Forming the Opinion that Involuntary Admission is Required

The decision to complete a Medical Certificate (Form 4) can be based on the examination only, however physicians are expected, as much as possible, to ensure their decisions are based on a variety of sources (such as information from family members or clinical records). Cultural considerations, such as language or customs, may be important in the assessment.

6.0 Completing the Medical Certificate – Form 4

The Medical Certificate (Form 4) includes the four criteria from the Mental Health Act. The physician must be of the opinion all four criteria are met. The reasons for the physician’s opinion must be summarized on the Medical Certificate.

Criteria for Involuntary Admission:

1 – “Person with a mental disorder”

As defined in the Mental Health Act, the person must have a “disorder of the mind that requires [psychiatric] treatment and seriously impairs the person’s ability to (a) react appropriately to the person’s environment, or (b) to associate with others.”

Indications (symptoms) of mental disorder might include hallucinations, delusions, irrational thinking, manic excitement, depression or difficulty relating to others. To qualify, the symptoms must be amenable to psychiatric treatment and severe enough to seriously impair the person’s functioning.

2 – Requires psychiatric treatment in or through a designated facility

The physician’s opinion that the person requires psychiatric treatment may be based on the diagnosis arising from the medical examination, symptoms or previous treatment.

The physician must also be of the opinion that psychiatric treatment can only be provided in an inpatient setting. For example, the person may have refused voluntary outpatient services.

3 – Requires care, supervision and control in or through a designated facility to “prevent the person’s...substantial mental or physical deterioration” OR “for the protection of the person...or the protection of others”

The person must meet criteria in 3.a. or 3.b.

3.a. Prevent the person’s substantial mental or physical deterioration

There must be information that without treatment this person will likely deteriorate to the point that they would qualify under 3.b. -- they would need the protection of an inpatient setting. Helpful information for forming this opinion might include a previous history of acute episodes with significant deterioration and current symptoms that suggest similar deterioration is likely to occur.

3.b. Requires care for the protection of the person or the protection of others

The B.C. Supreme Court (McCorkell v. Riverview Hospital) has ruled that the term “protection” goes beyond physical dangerousness. Physical, social, family, vocational or financial harm may be included in the definition of “protection” from serious harms caused by a mental disorder.

Protection of self can include non-physical harms, as mentioned above, or suicidal threats or gestures. Protection of others does not need to be evidenced, for example, by a physical blow. Threats or delusions can also be evidence of a need for protection.

4 – Cannot be suitably admitted as a voluntary patient

Someone who lacks the capacity to consent to admission or treatment cannot be admitted as a voluntary patient. A person may also be unsuitable for voluntary admission if there is a safety concern. For example, if the patient might leave hospital and commit suicide.

7.0 Admissions: Police Intervention

The Medical Certificate has a space for the physician to check off whether the person was brought to the physician by a police officer under section 28(1) of the Act.

8.0 Transportation

The Mental Health Act provides authority for anyone to transport the patient to a designated facility once the Medical Certificate is completed. Ordinarily, the ambulance service would be called. If it is safe to do so, a relative can transport the person to hospital.

9.0 Admission, Care, Treatment and Leave

One Medical Certificate is authority for the patient to be apprehended, transported and admitted to the hospital for up to 48 hours. Within that 48 hours, a second certificate must be completed to extend the admission for up to one month or the patient must be discharged. For further extensions, a Renewal Certificate completed by a hospital physician is required. The Renewal Certificate must be completed at one-month, three-month and, thereafter, six-month intervals before the current certificate expires.

Patients’ rights include the right to be informed about access to the Review Panel and courts and to obtain a second medical opinion on the appropriateness of their treatment.

Involuntary patients may be placed on leave in the community and community physicians may be authorized to manage the leave.

10.0 Liability

A physician is not liable in damages as a result of signing a Medical Certificate in good faith and with reasonable care (section 16).

11.0 Forms

The Medical Certificate and other Mental Health Act forms may be downloaded from the Ministry of Health, Mental Health and Addiction Services Website at: http://www.health.gov.bc.ca/mhd

Blank photocopied forms and completed faxed forms are legal. A photocopy of a completed form that is mailed needs to be marked “certified true copy” and signed.

12.0 When a Person Refuses to be Examined by a Physician

If a physician examination is not possible, there are two ways to obtain involuntary admission:

1. Police

Police officers have powers under the Mental Health Act, section 28 (1), to apprehend anyone who (a) is acting in a manner likely to endanger the person’s own safety or that of others and (b) seems to have a mental disorder. The police may take the person to a physician, usually at a hospital, for an examination.

2. Judge

Anyone (this is usually a relative, but may be a physician) may go to the court and request and complete a Form 9, Application for Warrant. This is an application to the provincial court for someone to be taken for a physician’s examination. The applicant must have good reason to believe the person apparently has a mental disorder and apparently meets the criteria used by a physician for involuntary admission to a designated facility (up to 48 hours).

13.0 More Information

The director of the nearest designated facility can provide more information about involuntary admission. The Ministry of Health document, Guide to the Mental Health Act, is available on the Ministry’s Mental Health and Addiction Services Website at: http://www.health.gov.bc.ca/mhd.

Ministry staff knowledgeable about the Mental Health Act may be contacted by calling [250] 952-1645 or [250] 952-1608.