COMUNICADO DO MOVEMENTO GALEGO DA SAÚDE MENTAL EN RELACIÓN CON SITUACIÓN DE USO DE TEC FORZOSO NO HOSPITAL PROVINCIAL DE CONXO
Desde hai uns días, un medio de comunicación publica de forma repetida noticias sobre o caso da familia dun paciente ingresado na Unidade de Hospitalización Psiquiátrica do Hospital Provincial de Conxo. Están preocupados e desconformes coa decisión dun ingreso involuntario, e da aplicación da Terapia Electroconvulsiva (TEC).
O caso está xudicializado, xa que requiriu a intervención de fiscalía e xuíz, tanto para confirmar a involuntariedade do ingreso (como é preceptivo por lei) como, e isto é unha excepcionalidade, para autorizar a administración do TEC, tras demanda de paralización da familia.
Os detalles do caso transcenden a partir do testemuño familiar a este medio de comunicación e as aportacións que eles fan do texto do auto xudicial. Evidentemente, nin xs profesionais nin a institución sanitaria nin os órganos xudiciais poden realizar declaracións, só pena de vulnerar ao dereito á confidencialidade dos datos de saúde e salvagarda da intimidade da persoa ingresada.
Coa prudencia debida, e máis aló da situación concreta difundida, debemos sinalar varios aspectos cruciais desde unha perspectiva de dereitos das persoas usuarias dos servizos de saúde mental:
1-. Cando se produce unha situación de conflito entre paciente-achegadxs-profesionais, esta debe valorarse como un fracaso na atención asistencial, unha ruptura da necesaria actitude de colaboración e coidado no obxectivo compartido de mellorar a situación clínica da persoa ingresada/atendida, polo que debemos colocar todo o esforzo posible en restaurar e evitar no futuro este tipo de problemáticas, xa que ten repercusións moi negativas tanto no tratamento do proceso agudo (momento no que se está actualmente) como na continuidade asistencial que con moita probabilidade requirirá a persoa.
É unha experiencia de perda de confianza nas institucións sanitarias, sinalada de forma repetida por quen percibiu como se lle impuñan medidas coercitivas (ingresos involuntarios, contención mecánica, administración de medicamentos sen información suficiente ou sen consentimento expreso) e leva a que non volvan a pedir axuda especializada cando o necesitan. Convértese, en non poucas ocasións, nunha experiencia traumática que re-vitimiza (é frecuente que as persoas con problemas de saúde graves teñen sufrido malos tratos e abusos).
Por este motivo, debería tratarse cada situación de ruptura da relación terapéutica que leve a un resultado tan negativo (malestar importante en paciente e achegadxs, inquedanza no equipo asistencial, xudicialización, etc) como un evento centinela ou incidente crítico, de tal forma que se poña en marcha o procedemento para analizar e evitar situacións futuras. Estes son os verdadeiros procesos de calidade asistencial, seguridade dxs pacientes e satisfacción dxs profesionais que debera promover o SERGAS. Son procedementos que non pretenden culpabilizar a ningún dos implicadxs senón buscar a excelencia nos coidados. Para elo, deben contar coa participación de todos os colectivos, incluídos primeira persoa.
2.- A atención á saúde mental respectuosa cos dereitos humanos é unha tarefa pendente desde hai longo tempo. A propia normativa sanitaria xeral experimentou, nas últimas décadas, un proceso de transformación radical para equilibrar a toma de decisións sobre os coidados co respecto aos dereitos das persoas usuarias en termos de liberdade de decisión, información e consentimento, elección entre alternativas, intimidade ou seguridade.
Hai certos colectivos sobre os que seguen pesando prexuízos e estereotipos sobre a súa competencia para decidir e actuar, e pasan a ser actores pasivos na toma de decisións clínicas ou xurídicas. É o caso, en xeral , das persoas con discapacidade, e moi particularmente nas discapacidades psicosociais.
A Convención sobre os Dereitos das Persoais con Discapacidade de 2006, ratificado por España en 2007 e en vigor un ano despois, é o resultado da loita destes colectivos polo seu dereito a decidir, á dignidade inherente á persoa e a defensa contra vulneracións sistemáticas dos dereitos humanos. No seu artigo 25, sinálase que “esixiran aos profesionais da saúde que presten ás persoas con discapacidade atención da mesma calidade que ás demais persoas sobre a base do consentimento libre e informado, entre outras formas mediante a sensibilización respecto aos dereitos humanos, a dignidade, a autonomía e ás necesidades das persoas con discapacidade a través da capacitación e a promulgación de normas éticas para a atención á saúde nos ámbitos público e privado”.
En España, o desenvolvemento normativo dos principios da Convención prodúcese moi lentamente. Non é ata o ano 2021 cando se reforma a lexislación sobre o exercicio da capacidade xurídica das persoas que ata ese momento estaban incapacitadas para tomar decisións económicas, patrimoniais, xurídicas ou sanitarias. A lei 8/2021, de 2 de xuño, supón un cambio revolucionario, ao pasar do modelo paternalista de substitución a outro onde a vontade, desexos e preferencias da propia persoa ocupa o lugar central. Ninguén poderá substituír esa capacidade, nin dará por feito que se teña esa potestade, nin profesionais nin familiares.
Tampouco debe darse por feito que o emprego dunha medida coercitiva, como é a do ingreso involuntario supón de facto poder impoñer outras medidas ou tratamentos durante a estancia hospitalaria.
Neste sentido, e a pesar de que está recollido no Plan de Saúde Mental de Galicia poscovid-19, non se realizou ningún avance efectivo nos obxectivos de consolidar dereitos, como é a eliminación das contencións mecánicas (e outros procedementos coercitivos) e a creación e funcionamento do documento de vontades anticipadas para persoas usuarias dos servizo de saúde mental. É un síntoma da pervivencia dos estereotipos que rodean ás persoas diagnosticadas como incapaces para decidir sobre aspectos fundamentais da súa vida.
Só en casos de extraordinaria necesidade e urxencia haberá que establecer medidas de apoio externo, sempre axustadas aos principios de necesidade e proporcionalidade, e durante o tempo estritamente necesario, para a situación concreta que se precise ese apoio e notificando ao Ministerio Fiscal. Este, en 2022 concreta na Instrución 1/2022, de 19 de xaneiro, os procedementos de vixilancia e control sobre medidas coercitivas como poden ser o uso de medios de contención mecánicos ou farmacolóxicos en unidades psiquiátricas.
Revisan os principios que se deben asegurar no uso de medios coercitivos, como son os tratamentos forzosos: excepcionalidade, individualización, necesidade, proporcionalidade, idoneidade, gradación, mínima intensidade posible, tempo estritamente necesario e transparencia.
É importante clarificar dentro deste proceso no que a persoa non está en condicións temporais de entender, expresar as súas preferencias e dar consentimento, cal será a actitude asistencial de coidado e atención que integre todos os recursos e coñecementos interdisciplinares a disposición do paciente. Dito doutro xeito, esgotar todos os tratamentos posibles non se pode referir exclusivamente aos tratamentos farmacolóxicos. Debe cambiar a cultura asistencial do centro sanitario para ampliar o marco de prestación de atención: os coidados de enfermería; as terapias psicolóxicas, as terapias ocupacionais e os tratamentos farmacolóxicos deben formar parte integrada e ordinaria no plan individualizado de tratamento, e ser discutido e proposto en reunións de equipo.
Xa o Defensor del Pueblo, no seu informe como Mecanismo Nacional de Prevención da Tortura e outros tratos ou penas crueis, inhumanos e degradantes, tras a visita de seguimento ao Hospital Psiquiátrico de Conxo, advertía dun funcionamento moi vertical do equipo, con escasa coordinación interdisciplinar e sen a integración de pacientes ou asociacións na toma de decisións sobre a funcionalidade do centro nin as abordaxes terapéuticas. Esta observación sobre o hospital psiquiátrico pódese estender a todos os dispositivos asistenciais de saúde mental.
3.- O uso do TEC
Escapa os obxectivos deste comunicado, pola extensión que se precisaría, realizar unha análise da pervivencia do uso do TEC nos servizos de saúde mental. Temos, sen embargo, que recordar que a denominada terapia electroconvulsiva é un procedemento invasivo e non exento de riscos. Con certa frecuencia aparecen episodios de amnesia ou confusión pos-TEC, así como cefaleas e náuseas, e pode haber complicacións cardíacas, respiratorias ou lesións bucodentais, entre outras.
Require anestesia e monitorización, non é realizado baixo condicións de urxencia vital senón de xeito programado e sen ser un acto único. De maneira xeral, adoitan realizarse de media 2-3 sesións por semana, e sen poder anticipar o número de sesións que se van a requirir, segundo os propios documentos de consenso elaborados por algunhas sociedades profesionais de psiquiatría.
Non é un tratamento preventivo.
Isto levaríanos a expor a dúbida de se seguiron os principios arriba sinalados, entre outros, os de urxencia, proporcionalidade e mínima intensidade posible, ata que o propio paciente, e só o paciente, puidera dar o seu consentimento a tal medida. Máxime se se están a tomar xa outras decisións para a seguridade do paciente, como son o acompañamento enfermeiro reforzado e a ampliación do tempo de ingreso ata esperar unha melloría suficiente.
— — — — —
Cómpre progresar noutra cultura asistencial en saúde mental que avance na óptica dos dereitos humanos, promova un trato digno para as persoas usuarias e posibilite unha actuación profesional máis acorde coa complexidade e riqueza do coñecemento que sustenta as disciplinas sanitarias participantes na atención neste eido da sanidade.
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