SERVICE AGREEMENTS FOR CASES OF CRISIS AND SUICIDE : V V; ^ 1

Transcription

1 SERVICE AGREEMENTS FOR CASES OF CRISIS AND SUICIDE : V V; ^ 1 I t REHABILITATION CENTRES HOSPITAL CLSC SUICIDE PREVENTION CENTRE REGIONAL INFO-SANTÉ AMBULANCE SERVICES POLICE SERVICES REGIONAL HEALTH AND SOCIAL SERVICES BOARD OF THE LAURENTIANS WM 401 L INTEGRAL VERSION JULY 2001 m m

2 Translated by Mrs Ellen Lakoff Publié également en français sous le titre Ententes de services pour les situations de crise et suicide ISBN ISBN Dépôt légal : 3 ième trimestre 2002 Bibliothèque nationale du Québec Bibliothèque nationale du Canada

3 1//H Ho] Institut national de santé publique du Québec 4835, avenue Christophe-Colomb, bureau 200 Montréal (Québec) H2J3G8 Tél.: (514) WORKING COMMITTEE Members of the working committee Bourassa, Manon Bousseau, Bernard Campbell, Julie K. Corbeil, Daniel Crevier, Michel Dumaraix, Nathatalie Galarneau, François Jacques, Daniel Lachaîne, Colette D. Lafrenière, Hélène Lampron, Isabelle Larose, Diane Marsolais, Gilles Masse, Pierre Morin, Gilles Pelletier, Michèle Provencher, Claudette Special contributors Jodoin, Colette Séguin, Pierre P. Yelle, Richard Composition Lafrenière, Hélène Editing Lachaîne, Colette D. Coordination Désy, Jean Head-nurse, emergency department of Hôtel-Dieu de Saint-Jérôme Director, Sûreté municipale de Mirabel Director, le Faubourg Suicide Prevention Centre Coordinator, adult psychiatric programme, Hôtel-Dieu de Saint- Jérôme Owner, Ambulances Michel Crevier inc. Psychiatrist, CH Saint-Eustache Director of Operation, Services préhospitaliers Laurentides- Lanaudière Adjoint à la Sûreté du Québec, Montreal, Lanaudière, Laurentides, Laval district, Bureau de la surveillance du territoire Medical coordinator, Emergency prehospital services, Régie régionale de la santé et des services sociaux des Laurentides Planning, programming and research, Régie régionale de la santé et des services sociaux des Laurentides, project supervisor Chief, programme administration, Info-Santé régionale, ambulatory clinic and specimen collection centre, CLSC Thérèsede-Blainville Clinical counsellor in mental health, CH et CR Antoine-Labelle Clinical advisor for crisis assistance services, Basses-Laurentides Local coordinator for mental health, CLSC Arthur-Buies Local coordinator for mental health, CLSC-CHSLD des Trois- Vallées Director of professional services, Hôtel-Dieu de Saint-Jérôme Planning and programming officer, physical health, Régie régionale de la santé et des services sociaux des Laurentides Community relations advocate, Sûreté du Québec Vice-President Legal Affairs, Services préhospitaliers Laurentides- Lanaudière Mental health coordinator, Centre du Florès (crisis shelter) Planning, programming and research, Régie regionale de la santé et des services sociaux des Laurentides Medical coordinator, Emergency prehospital services, Régie régionale de la santé et des services sociaux des Laurentides Programme coordinator for mental health, social adaptation and addiction, Régie régionale.de la santé et des services sociaux des Laurentides I

4 FOREWORD This document is the official version of the Laurentian Region's "Service agreements for crisis and suicide situations" in the Laurentian region. The document describes the missions, roles and responsibilities of all the resources involved, and, more specifically, the procedures that allow the service agreements to be applied. We held a series of consultations over a period of several months, and, thanks to the collaboration of all the members of the working committee, we were able to obtain the concessions needed from all parties to conclude these service agreements, which appear to satisfy all of those who are involved. This version was presented for signature, and solidifies relationships required to coordinate services for clients with problems due, in large part, to their mental state. The Loi sur la protection des personnes dont l'état mental présente un danger pour elles-mêmes ou pour autrui (L Q. 1997, c:75) (An Act respecting the protection of persons whose mental state is a danger to themselves or to others) and the Stratégie québécoise d'action face au suicide fquebec Suicide Action Strategy,) are means which will be implemented in May, 2001, and which have been put in place to establish a better response to the needs of these clients We want to thank all who took part in this process, and, in particular, the members of the working committee and the support staff who helped coordinate the integrated presentation of this document m

5 CENTRE AND SERVICES INVOLVED IN THE SERVICE AGREEMENTS Establishments Centre du Florès CH et CR Antoine-Labelle Hôpital d'argenteuil CH Hôtel-Dieu de Saint-Jérôme Centre hospitalier Laurentien Centre hospitalier Saint-Eustache CLSC d'argenteuil CLSC Arthur-Buies CLSC Jean-Olivier-Chénier CLSC des Hautes-Laurentides CLSC-CHSLD des Pays-d'en-Haut CLSC Thérèse-de-Blainville CLSC-CHSLD des Trois-Vallées Info-Santé régional Community Organization Le Faubourg Suicide Prevention Centre Alain Gervais Robert Bergeron Claudette Lagacé Lucie Dauphin Jacques Gaudette Mario Larivière Suzanne Gougeon Georges LeGal Gylaine Boucher Denis Bouchard Jacqueline Gagnon Jocelyn Ouellet Christine Lessard Jocelyn Ouellet Julie K. Campbell General Director General Director Interim General Director General Director General Director General Director Interim General Director General Director General Director General Director General Director General Director General Director General Director Director Ambulance Services Ambulance André Fournier enr. Ambulance Mont-Tremblant inc. Ent. Bouchard, Ouellette et Riopel inc. Kanesatake Mobile Service Inc. Les ambulances Gilles Thibault Les Ambulances Laurentides Inc. Les Ambulances Michel Crevier Inc. Service d'ambulance bénévole Hatzoleh Services préhospitaliers Laurentides-Lanaudière ltée (SPLL) André Fournier Serge Gagnon Yvon Bouchard Ronald Bonspille Gilles Thibault Gilles Légaré Michel Crevier Israël Lowen Lise Goyer Director Director Director Director Director Director Director Director Director V

6 CENTRE AND SERVICES INVOLVED IN THE SERVICE AGREEMENTS (next) Régie intermunicipale de police de Rivière-du- Nord Villle de Blainville Ville de Boisbriand Ville de Deux-Montagnes Ville de Lachute Ville de Lorraine Ville de Mirabel Ville de Morin-Heights Ville de Rosemère Ville de Saint-Adolphe-d'Howard Ville de Sainte-Adèle Ville de Sainte-Agathe-des-Monts Ville de Sainte-Thérèse Ville de Saint-Eustache Ville de Saint-Jérôme Ville de Mont-Tremblant Ville de Saint-Sauveur Sûreté du Québec Laurentides Jean Lalonde Albert Stringer Michel Foucher Marc Henrico André Montpetit Serge Charrette Bernard Bousseau Ernest Wood Daniel Thibodeau Jean-Guy Lussier Jean Lalonde Pierre Lanthier Claude Brosseau Yves Morency Pierre Bourgeois Pierre Bernaquez Jean Pagé Jacques Beaupré Police Chief Police Chief Police Chief Police Chief Police Chief Police Chief Police Chief Police Chief Police Chief Police Chief Police Chief Police Chief Police Chief Police Chief Police Chief Police Chief Police Chief Commanding Officer, Montreal, Laurentides, Lanaudière and LaVal districts (MLLL) VI i

7 TABLE OF CONTENTS Page INTRODUCTION 1 CHAPTER 1 ORIENTATIONS RETAINED FOR THE SERVICE AGREEMENTS 3 CHAPTER Objectives of the agreement Goals and anticipated results Underlying principles of collaboration Potential clientele 4 BILL # 39 AND THE QUEBEC SUICIDE ACTION STRATEGY 5 CHAPTER The Act respecting the protection of persons whose mental state is a danger to themselves or to others An Act of exception The Quebec Hospital Association's (AHQ) guidelines Rights of appeal of people in preventive confinement The Quebec Suicide Action Strategy Crisis Support services Intervention 7 MEANS OF ACCESS AND COLLABORATION Request for help received through emergency call services Procedures when a person is brought to the hospital emergency room Request for help received through the health and social services network Procedures when a person is brought to the hospital emergency room Referrals to the crisis shelter «Centre d'hébergement de crise Le Soleil Levant/Centre du Florès» Specific agreements with Le Faubourg Suicide Prevention Centre 21 CONCLUSION 23 BIBLIOGRAPHY 25 i

8 APPENDIX Appendix 1: Appendix 2: Appendix 3: Appendix 4: Appendix 5: Appendix 6: Appendix 7: Appendix 8: Mission, role and responsibilities of the various resources that may respond in cases of crisis or suicide Glossary Request for assistance in crisis-suicide cases that enter via emergency call services Request for assistance entered through the health and social services network Form to transmit information regarding crisis situations in the Laurentian Region Extract from the Act respecting the protection of persons whose mental state is a danger to themselves or to others L.Q. 1997, c. 75 Extracts from the Quebec Charter of Human Rights and Freedoms Forms to be signed regarding the Service agreements for cases of crisis and suicide ii

9 INTRODUCTION In applying Bill # 39, An Act respecting the protection of persons whose mental state is a danger to themselves or to others and the Quebec Suicide Action Strategy, the Regional Health and Social Services Board of the Laurentians mandated a working committee to draft cross-sectorial service agreements for crisis and suicide situations. The working committee tried to harmonize services for these clients, or, more specifically, according to the terminology used in the major orientations of the minister, they tried to establish which situations require concerted service delivery for people in crisis situations. To do this, we determined which were the most probable situations and drafted procedures for each of these. Please note that the situations that have been described do not all fall under the auspices of Bill # 39 and some are several degrees removed from the level of grave and immediate danger. Because coordination is essential to provide proper services for these clients, the committee also set forth clear-cut roles for each service and resource. You will find a short description of these roles in Appendix 1, along with methods of referral and collaboration that are requisite for this type of coordination. The service agreements should consolidate the coordination mechanisms by linking all the partners (CLSC, hospitals, suicide prevention centre, community organizations, etc.). However, intervention protocols (internal procedures), must still be drafted by each resource. The service agreements will support the application of the protocols by facilitating access to the required services. Nonetheless, these coordination mechanisms must be recognized by all those who are involved in these matters. Finally, we must remember that these clients are particularly vulnerable, whether they present a grave danger to themselves or others or whether they are in a suicide crisis. Therefore, when drafting the service agreements, the members of the committee considered the need for rapid action and intervention adapted to the circumstances. They also considered the need to avoid congested hospital emergency rooms, while ensuring essential services and suitable follow-up for people in crisis situations. The primary goal of this process is, above all, to provide fast and pertinent access to adapted services for these clients and help them return to a satisfactory state of equilibrium. -1 -

10 EH Chapter 3 ORIENTATIONS RETAINED FOR THE SERVICE AGREEMENTS 1.1 Objectives of the agreement The cross-sectorial resources involved in applying Bill # 39 1 and the Quebec Suicide Action Strategy agree to establish means of collaborating to provide services for people in suicide crisis situations when the specific needs of these people requires the vocation, the services, or the programmes offered by another establishment, organization or community resource. > Whereas, above all, we must facilitate and simplify access to the services that are required; > Whereas the request for services may come from emergency call services (for example: 911) or through the health and social services network; > Whereas efficient coordination of clinical activities would ensure that the client receives the necessary services and that he does not "slip through the cracks". It is therefor agreed that this document describes the means of collaboration amongst the various parties providing services, and defines, in the appendices, the missions, roles and responsibilities of each resource. 1.2 Goals and anticipated results The goals of these service agreements, are to link the services that are offered and coordinate the teamwork of the various people who may be called upon to respond to a request for help in a crisis situation. The anticipated results are fast and concerted action to respond to the needs of people in crisis situations, and, above all, a coordinated response in which everyone is aware of what he must do and what is expected of other services. We also want to see the development of support, mutual aid, and an increase in cross-sectorial alliances. 1.3 Underlying principles of collaboration Collaboration among the various partners takes place when there is a common will to improve the quality of client services. A global approach towards clients is preferred. This collaboration should promote greater complementarity of services, and provide continuous support for clients in the process of seeking services. This collaboration should be based upon a shared set of *An Act respecting the protection of persons whose mental state is a danger to themselves or to others, hereinafter called the Act -3-

11 values or principles, notably with regard to attitudes of respect, openness, understanding and courtesy. In addition to other elements, functional collaboration requires: > knowledge of the services that other partners provide, and of how the other partners work within their organizations; > establishing a common language regarding the client's needs; > complementarity of services among the various resources; > recognition of the fields of expertise of the different partners; > respect for the mission of the different resources that are brought into play; > total and sustained involvement of the diverse administrations in promoting and realizing this collaboration; > setting up territorial mechanisms and a regional mechanism to ensure promotion, follow-up and revision of cross-sectorial collaboration. 1.4 Potential clientele People in crisis situations that may require intervention experience severe problems, primarily associated with: > severe and persistent mental health problems; > suicide; > self-mutilation; > transitory mental health or psychosocial problems; > problems of aggression; > alcoholism and drug addiction; > psychological distress; > homelessness.

12 EH Chapter 3 BILL # 39 AND THE QUEBEC SUICIDE ACTION STRATEGY 2.1 THE ACT RESPECTING THE PROTECTION OF PERSONS WHOSE MENTAL STATE IS A DANGER TO THEMSELVES OR TO OTHERS This law was adopted and ratified on December 18, 1997 and came into force on June 1; It is not yet among the revised statutes, and therefor bears the number L. Q c. 75. It replaces the Mental Patients Protection Act and completes the dispositions of the Civil Code with regard to residential care and psychiatric evaluation. Before this law was adopted, this process required a court petition. The new law introduces the diversion of the process to admit a person to a health establishment against his will. The goal of this law is to ensure better protection for the person concerned or for others. In order to provide this protection, fundamental rights that were formerly recognized in other laws are affected. In this sense, the law is called an act of exception and, under certain strict conditions, it overrules the necessity for consent, by temporarily depriving a person of their freedom so that they may be taken to an institution against their will to be examined in order to ensure their safety or the safety of others An Act of exception The Act is the only legal basis that,authorizes depriving a person of his freedom because his mental state constitutes a danger to himself or to others.... No particular mental illness, in of itself, results in the Act being applied. The Act can be applied only on the basis of a mental state that is dangerous to the person or to others. In addition, it is only applied after other forms of intervention have been tried, and there is no other solution to ensure the protection of the people involved. The Act does not pertain to treatment, but only to confinement. Finally, because these judicial rules affect people's fundamental rights, they are principles of exception and must be rigorously monitored. -5-

13 2.1.2 The Quebec Hospital Association's (AHQ) guidelines > Ensure the right balance between exercising the rights of people whose mental state is a danger to themselves or to others, and the right to intervene with these people when their safety or the safety of others is in danger; > Promote a rapid and adequate response as close the person's home as possible; > Prioritize a humane and normalizing approach at each step of the process of intervention; > Reflect the spirit and the letter of the Charter of Rights and Freedoms, the Quebec Civil Code and other laws that are in force Rights of appeal of people in preventive confinement > The right to information: - from the peace officer - from the establishment > The right to be informed of your rights; > The right to receive information about your condition; > The right to communicate; > The right to change institutions under certain conditions; > The right of appeal to the Quebec administrative tribunal; > Other rights (all those that are recognized by the Charters, the Quebec Civil Code and all other applicable laws). 2.2 THE QUEBEC SUICIDE ACTION STRATEGY In this same procedure we included crisis situations that involve suicide. The Quebec Suicide Action Strategy was a guide in drafting the inventory of existing resources, and in the process of establishing a range of essential services to help apply the Act, attain the objectives of the Quebec Suicide Action Strategy, and allow better service coordination and effective action. Establishing crisis support services and consolidating the network preceded consultation with other sectors of activity. Finally, clearly identifying crisis intervention services should encourage the use of measures other than legal proceedings, and,help prevent suicides Crisis Support services Crisis support services were set up to according to two organizational principles and two types of intervention, e.g.: services that are available at all times (24/7), and local services. The plan was to establish a telephone hot line service and, for emergencies, to set up mobile teams that could respond in emergency situations within the local area where the crisis occurs. Crisis emergency services are always based on intervention by a person specially trained to reduce tension, prevent endangerment and steer the person in crisis toward more specific, long term services. CLSC crisis support services, including regional Info-Santé, have the mandate to evaluate the crisis (according to the Act). Le Faubourg Suicide Prevention Centre has this same mandate for their clients.

14 2.2.2 Intervention Intervention can take place by telephone or in person. Some CLSC crisis services have mobile crisis teams who can travel to where die crisis is happening. It is importante specify that intervention with people in trouble must primarily try to defuse the crisis and avoid hospitalization. The designated responder can ask a peace officer to transport the person in crisis to an establishment, as defined in article 6 of the Act, without the person's consent, only after an attempt has been made to reduce the crisis level and the danger remains grave and immediate. In addition to attempting to defuse the situation, the person at the scene evaluating the situation can also propose alternatives to resolve the situation and obtain the person's consent if the person's condition requires emergency care. Therefore the mission of the mobile crisis teams is to defuse the crisis and prevent hospitalization without consent by using other resources available in the community. The party who is designated to respond in crisis situations must therefore: > estimate the level of danger and offer the assistance that the situation requires; > in case of grave and immediate danger, try to obtain consent to protect the person from danger (hospital emergency room, crisis shelter, or other); > if consent is refused, ask an officer of the peace to transport the person to an establishment as defined in article 6 of the Act, and transmit all pertinent information to the peace officer responsible for transporting the person. Finally, dangerousness is thé only condition that allows application of the Act (C.C.Q.,art.27). The law defines two levels of danger 2 : > the person's mental state constitutes a danger to himself or to others. This level can lead to interim confinement (authorized by a court of law to allow for a psychiatric evaluation); > the person's mental state constitutes a grave and immediate danger to himself or to others. This level can lead to preventive confinement without authorization of a court of law and without consent. This is therefore an exceptional situation that requires both proof of danger and urgency and immediate intervention to protect the life or physical integrity of the person or of others. 2 See appendix 2 ; "Glossary" for other definitions. -7-

15 Imperatives of crisis intervention : > intervene at the scene of the crisis; > intervene as quickly as possible with the person and his entourage to prevent suicide and mental deterioration; > act upon the stress factors that caused the crisis (to prevent recurrence); > intervene with the person's collaboration (if his condition allows); > intervene with the assistance of the friends and family; > ensure the continuity of the intervention; > act in concert; > try to keep the person at home; > try to obtain the person's consent; > try to avoid hospitalization and promote alternatives if possible (ex.: crisis shelters).

16 EH Chapter 3 o Q MEANS OF ACCESS AND COLLABORATION When crisis intervention deals with a crisis involving a person's mental condition, the intervention may be subject to provisions of the Act respecting the protection of persons whose mental state is a danger to themselves or to others LQ. 1997, c. 75. WHEREAS any person who is competent may refuse care or refuse to be taken to a hospital, and because competency to consent in an informed and voluntary manner is evaluated at the time of the intervention; WHEREAS all human beings have the right to personal inviolability and dignity and these fundamental rights cannot be affected unless authorized according to the Act; WHEREAS, according to article 6 of the Act respecting the protection of persons whose mental state is a danger to themselves or to others, a police office may bring a person against his will and without authorization from a court of law, to an establishment as defined in article 6 : 1) if requested to do so by a person working for crisis assistance services who has assessed the person's mental state as constituting a grave and immediate danger to himself or to others, or, 2) on request from a parent or from a legal guardian of a minor or another person as defined in article 15 of the Quebec Civil Code, when no one from crisis assistance services is available to assess the situation within a reasonable amount of time. In this case, the peace officer must have significant reason to believe that the person's mental state constitutes a grave danger to himself or to others; WHEREAS the person working for crisis assistance services or for a CLSC psychosocial reception service is the first person designated to assess the crisis; WHEREAS the regional Info-Santé psychosocial worker is the person designated to assess the crisis situation by telephone when the crisis occurs outside of CLSC opening hours; WHEREAS the person intervening for the crisis shelter centre can assess the crisis involving a person who is staying at the shelter; WHEREAS the person intervening for Le Faubourg Suicide Prevention Centre can also assess their clients' crisis situation by telephone; WHEREAS, according to the Act, the ambulance technician does not have the authority to care for and transport a person in crisis against his will, unless the person is not able to give his consent and the situation is urgent; -9-

17 WHEREAS the police officer is responsible for maintaining order and public security and for protecting life; WHEREAS the use of force to control or restrain a person in crisis must be justifiable and reasonable, considering the physical and mental condition of the person; WHEREAS it is important to intervene quickly and in a fashion that is adapted to the needs of people in crisis, and to avoid congestion of hospital emergency departments and delays in returning ambulance attendants and police officers to service; WHEREAS the specific needs of people in crisis situations can be, in certain circumstances, met by organizations and resources in the community according to their various missions, resources and programs; WHEREAS intervention with people in crisis situations must first attempt to defuse the crisis and avoid hospitalization; WHEREAS the person who travels to intervene in crisis situations has certain work hours and holidays, and is not always able to get to the scene of a crisis within an effective time to assess the crisis; THEREFORE it is agreed that the various workers (police, ambulance technicians, people designated to assess crisis situations) will act in the following manner and in accordance with the situation. 1 3.Ï Request for help; received through emergency call services 3 ; Situation # 1 => The person is in crisis, there is no evident physical problem and the person accepts the support services that are offered. > The police officer or the ambulance technician, according to who arrives on scene first, calls the designated responder from the crisis scene, so that the designated responder can determine if the person's mental state constitutes a grave and immediate danger to himself or to others. The assessment can be carried out by phone or at the scene. > Following the assessment, if the designated responder considers that there is no grave and immediate danger to the person or to others and the person accepts the services that are offered, the person is left at the scene. > If the designated responder believes it may be dangerous to leave the person at home, even if the danger to the person is not grave and immediate, one of the possible alternatives is to obtain consent and bring the person to a crisis shelter. 3See Appendix 3: "Request for help received through emergency call services" (ex.: 911) - 10-

18 The designated responder cannot go to the crisis scene ^ The assessment is made by telephone. ^ Following the assessment, if the designated responder believes there is no grave and immediate danger to the person or to others, and the person accepts the support services that are offered, the person is left at home. When there is an ambulance technician at the scene, he records the name of the designated responder and the reasons for the responder's decision. ^ If, following the assessment, the designated responder believes it may be dangerous to leave the person alone even if there is no grave and immediate danger to that person or to others, and the person accepts the services that are offered, the designated responder may propose 1) intensive crisis follow-up; 2) crisis shelter (If the intervention takes place during the night, the shelter placement may be for the following day because there is no grave arid immediate danger); 3) or, if there is no family or friend to provide transportation, the person may be taken by ambulance to an establishment as defined in article 6 of the Act. In this case, the ambulance technician records the name of the designated responder and the reasons for the responder*s decision. Situation #2 => The person is in crisis, there is no evident physical problem but the person refuses the support services that are offered. > The police officer or the ambulance technician, according to who arrives on scene first, calls the designated responder from the scene of the crisis, so that the designated responder can determine if the person's mental state constitutes a grave and immediate danger to himself or to others. The assessment can be carried out by phone or at the scene. > Following the assessment, if the designated responder considers that there is no grave and immediate danger to the person or to others and the person still refuses the support services that are offered, the person is left at the scene. If there are ambulance technicians present, they document the refusal and record the name of the designated responder and the reasons for the responder* s decision. If the person accepts the support services, the designated responder helps make an appointment at a CLSC. > If, following the assessment, the designated responder believes the person is a grave and immediate danger to himself or to others, and the person still refuses the services that are offered, the police officer, assisted, if necessary, by the ambulance technician, escorts the person to an establishment as defined in article 6 of the Act.

19 > If the condition or the behaviour of the person in crisis justifies restraining the person on a stretcher for their own safety and/or for the safety of the police officer, the police officer can ask for help from the ambulance technicians. If necessary, the person in crisis is brought to an establishment, as defined in article 6 of the Act, in the ambulance with the police officer on board when circumstances allow and justify this measure. > If, after first refusing, the person accepts support services that are offered, the person is brought to an establishment as defined in article 6 of the Act in the ambulance. In this case, it is not necessary for the police officer to be on board the ambulance. However, if necessary, the officer may escort the ambulance to the establishment. The designated responder cannot go to the crisis scene ^ The assessment is made by telephone. ^ Following the assessment, if the designated responder believes there is no grave and immediate danger to the person or to others and the person accepts the support services that are offered, the person is left at home. When there is an ambulance technician at the scene, he records the name of the designated responder and the reasons for the responder's decision. ^ If, following the assessment, the designated responder believes it may be dangerous to leave the person alone, even if there is no grave and immediate danger to that person or to others, if the person accepts the services that are offered, and if there is no family or friend to provide transportation, the person may be taken by ambulance to an establishment as defined in article 6 of the Act. The ambulance technician records the name of the designated responder and the reasons for the responder's decision. Situation #3 => The person is in crisis, there is a physical problem that is not urgent and the person refuses the services that are offered. > The police officer or the ambulance technician, according to who arrives on scene first, calls the designated responder from the crisis scene so that the designated responder can determine if the person's mental state constitutes a grave and immediate danger to himself or to others. The assessment can be carried out by phone or at the scene. > Following the,assessment, if the designated responder considers that there is no grave and immediate danger to the person or to others and the person still refuses the assistance services that are offered, the person is left at the scene. The ambulance technicians at the scene document the refusal and record the name of the designated responder and the reasons for the responder's decision.

20 > If, following the assessment, the designated responder believes the person is a grave and immediate danger to himself or to others, and the person still refuses the services that are offered, the person in crisis is taken by ambulance to an establishment as defined in article 6 of the Act with the police officer on board when circumstances allow and justify this measure. The ambulance technicians record the names of the police officer and designated responder and the reasons for the decision of the designated responder. > If after first refusing, the person accepts the support services that are offered, the person is taken by ambulance to an establishment as defined in article 6 of the Act. In this case, it is not necessary for the police officer to be on board the ambulance. However, if necessary, the officer may escort the ambulance to the establishment. The designated responder cannot go to the crisis scene ^ The assessment is made by telephone. ^ Following the assessment, if the designated responder believes there is no grave and immediate danger to the person or to others and the person accepts the support services that are offered, the person is left at home. When there is an ambulance technician at the scene, he records the name of the designated responder and the reasons for the responder's decision. ^ If, following the assessment, the designated responder believes it may be dangerous to leave the person alone even if there is no grave and immediate danger to that person or to others, if the person accepts the services that are offered, and if there is no family or friend to provide transportation, the person is taken by ambulance to an establishment as defined in article 6 of the Act. The ambulance technician records the name of the designated responder and the reasons for the responder* s decision. Situation #4 => The person is in crisis, there is a physical problem and the person accepts the. services that are offered. > The person is taken by ambulance to the emergency department of the nearest hospital without telephoning the person designated to assess the crisis 4 4Because of the person's condition, it is not pertinent to refer to the designated responder from the crisis service. -13-

21 Situation # 5 => The person is in crisis, refuses help and services, and there is an urgent physical problem due to the person's mental condition (the person's life is in danger or the person is in a situation in which there is any likelihood he may suffer grave and permanent injury to his health if care and treatment are not applied within a short time). > After determining that the person constitutes a grave and immediate danger to himself or to others, and that the situation is urgent, the police officer helps the ambulance technicians rapidly transport the person to the emergency department of the nearest hospital by ambulance. In these circumstances, it is not necessary for the police officer to be on board the ambulance. The ambulance technicians record the name of the police officer and the reasons for his decision. > If no police officer is at the scene and the ambulance technicians determine that the situation is urgent and that the person is incapable of giving his consent to receive care, they proceed to transport the person by ambulance to the emergency department of the nearest hospital. The ambulance technicians do not telephone the designated crisis responder. Situation #6 => The person does not have a physical problem that is urgent, but is extremely disturbed and is a danger to himself and/or to others (uncontrollable aggressiveness), and must cease acting immediately in order to protect himself or others and no designated responder is available soon enough to assess the situation. > After determining that the person in crisis constitutes a grave and immediate danger to himself or to others, and that the situation is urgent, the police officer, with the help of the ambulance technicians, immobilizes and/or restrains the person on a stretcher to stop the person from injuring himself or others. The person is taken to an establishment as defined in article 6 of the Act, in an ambulance with the police officer on board, when circumstances allow and justify this measure. The ambulance technicians record the name of the police officer and the reasons for his decision. -14-

22 3.1.1 PROCEDURES WHEN A PERSON IS BROUGHT TO THE HOSPITAL EMERGENCY ROOM In every case in which a person is brought to the emergency department of a hospital, the ambulance technician must call the emergency department staff ( the assistant head nurse or the triage nurse) to warn them that a person in crisis is due to arrive. The designated crisis responder records information related, to the person in crisis when the assessment is made, and sends this information by fax to the hospital emergency department as soon as possible, so that it may be included in the person's file. In every case in which a police officer rides on board the ambulance to accompany a person in crisis, the police officer must unload his weapon and place it out of sight along with his supply of pepper spray, if applicable. In addition, the police officer must tell the person where he is being taken, advise them that they must submit to a psychiatric assessment, and advise them of their right to call their family and a lawyer immediately. As soon as a policeman brings a person to a hospital emergency department, with or without the assistance of ambulance technicians because the person is a grave and immediate danger to himself or to others, the triage nurse immediately tells the doctor on duty in the emergency department that the patient's condition requires an urgent assessment that will probably call for the use of restraints or isolation. The doctor who is so advised will decide what measures to use 5. This predicates that the establishment will act quickly to manage the case, and that the police officer and the ambulance technicians that are assisting will collaborate 6 with the staff to facilitate this rapid take over. In addition, the hospitals agree to mobilize their staff in order that the police officer may return to duty as quickly as possible. An awareness training programme will be launched to emphasize the importance of rapid action. Finally, before leaving the establishment, the police officer transmits all pertinent information to the people intervening in the case, and hands in the form entitled 'Form for transmission of information in crisis situations' 7. 5If there is a delay before the doctor can make the assessment, one possible measure that may be taken is a personal verbal order to use restraints or any other measure deemed appropriate according to the condition of the patient. The position statement "Emergency Triage" published by the Collège des médecins du Québec in January, 2000, specifies, in Appendix 3, that a patient who is extremely agitated must be classified Level II - exceedingly urgent, and this classification means that the patient should be seen by the doctor within 15 minutes. A patient with acute psychosis with or without suicidal ideation will be classed as Level III - urgent, and should be seen by the doctor within 30 minutes. 6For the purpose of this agreement, the collaboration of the police officer and the hospital staff means the interpretation adopted by the Sûreté du Québec regarding case management within the meaning of the article of the Act respecting the protection of persons whose mental state is a danger to themselves or to others LQ. 1997, c. 75. This position is based on the only power this Act confers upon agents of the peace, i.e.: to bring a person to an establishment against his will and without a court order. In consideration of the above, the Sûreté du Québec recognizes and respects the terms of this agreement, under the condition that they will reevaluate the methods of administration one year after the agreement is signed. 7See Appendix

23 After the doctor has examined the patient, the establishment, with the patient's consent, sends the designated responder the information resulting from the process, i.e.: the doctor's decision about the treatment planned for the person who was brought to the emergency department, with the goal of ensuring continuity of service for the person in crisis. If the establishment admits the person under preventive confinement or interim confinement, the establishment must advise him where he is being held, the reason for this measure, and of his right to immediately enter into contact with his family or a lawyer. Also, when the person leaves the hospital, the establishment must advise the person about the support services available in the community and/or refer the person to a CLSC or a community organization if required or pertinent In addition, if the Act applies and if the person has children under 18 years of age living with them, the designated responder or the police officer must ensure that the children are safe (call a friend or family member that can care for them) and must advise the Youth Protection Centre of the Laurentians regarding the case if the safety of the children is or could be compromised. 3.2 REQUEST FOR HELP RECEIVED THROUGH THE HEALTH AND SOCIAL SERVICES NETWORK 8 => The request for help may constitute a risk to the safety of the designated responder. > After assessing the situation by telephone, the designated responder can ask a police officer to accompany him to help him assess the crisis at the scene, or he can call the emergency call service (ex.:911). => The request for help does not seem to constitute any risk and the situation seems to be safe. > The designated responder, if necessary goes to the crisis scene and assesses the crisis situation. Result of assessment result # 1 : No grave or immediate danger and the person cooperates => The assessment indicates that there are elements of danger, but these are not grave or immediate, and the person cooperates. > According to the particular situation, the designated responder can make an appointment for the person at a CLSC for crisis follow-up or offer the services of a crisis shelter. If the designated responder believes that it may be dangerous to leave the person at home, he can, with consent, take the person to a crisis shelter. 8See Appendix 4: Process of "Request for help received through the health and social services network" -16-

24 The designated responder cannot go to the crisis scene ^ Following the assessment, if the designated responder believes there is no grave or immediate danger io the person or to others, and the person accepts the support services that are offered, the person is left at the scene. When there is an ambulance technician present, he records the name of the designated responder and the reasons for the responder' s decision. ^ Following the assessment, if the designated responder believes it may be dangerous to leave the person alone, even if there is no grave or immediate danger to the person or to others, and the person accepts the services that are offered, the designated responder can offer: 1) intensive crisis follow-up; 2) crisis shelter (because there is no grave and immediate danger, and if the intervention takes place during the night, the shelter placement may be for the following day.); 3) or, if there is no family or friend to provide transportation, the person may be taken by ambulance to an establishment as defined in article 6 of the Act. In this case, the ambulance technician records the name of the designated responder and the reasons for the responder's decision. Result of assessment # 2 : No grave or immediate danger and the person refuses to cooperate => The assessment of the crisis indicates that there are elements of danger, but these are not grave or immediate, and the person refuses to cooperate. > The designated responder gives the person the names, addresses and telephone numbers of the CLSC and Le Faubourg Suicide Prevention Centre if pertinent, so that the person may obtain help. > The designated responder may also refer other people involved in the situation, and in particular the person's friends and family : 1. to the means provided in the Civil Code that would allow them to obtain an order for a psychiatric evaluation; 2. to the regional organization ALPPAMM or to the Comité d'entraide en santé mentale in Mont-Laurier, to help them through the above process should the situation worsen. Result of assessment # 3: Grave danger is foreseeable but not immediate and the person cooperates => The assessment of the crisis indicates that grave danger is foreseeable, but the danger is not immediate, and the person cooperates. > The designated responder: 1. offers intensive crisis intervention or 2. brings the pérson to a crisis shelter or to the hospital emergency department

25 The designated responder cannot go to the scene ^ The designated responder offers intensive crisis intervention or. ^ lodging at a crisis shelter (if accessible) or ^ asks that the person be brought to a hospital emergency department. If there is no friend or family member to transport the person, as a last resort, the designated responder, if required, can ask the police officer, or the ambulance technicians with the help of the police, if necessary, to bring the person to an establishment as defined in article 6 of the Act. Result of assessment # 4: Grave danger is foreseeable but not immediate and the person refuses to cooperate => The assessment of the crisis indicates that grave danger is foreseeable but the danger is not immediate, and the person refuses to cooperate. > The designated responder gives the person the names, addresses and telephone numbers of the CLSC and Le Faubourg Suicide Prevention Centre if pertinent, so that the person may obtain help. > The designated worker refers the other people involved in the situation, and in particular the person's friends and family, 1. to the means provided in the Civil Code that would allow them to obtain an order for a psychiatric evaluation; 2. to the regional organization ALPPAMM or to the Comité d'entraide en santé mentale in Mont-Laurier, to help them through the above process should the situation worsen. Result of assessment # 5 : Grave and immediate danger with cooperation => The assessment of the crisis indicates that there is grave and immediate danger to the person or to others, and the person is cooperative. > The designated responder: 1. offers intensive crisis intervention or 2. brings the person to a crisis shelter or to a hospital emergency department. The designated responder cannot go to the scene ^ The designated responder offers intensive crisis intervention or asks that the person be brought to a hospital emergency department. As a last resort, if there is no friend or family member to transport the person, the designated responder, if the situation so requires, can ask the police officers, or the ambulance technicians with the help of the police, if necessary, to bring the person to an establishment as defined in article 6 of the Act

26 Result of assessment # 6: Grave and immediate danger with refusal to cooperate => The assessment of the crisis indicates that there is grave and immediate danger to the person or to others and the person refuses to cooperate. > The designated responder calls the police officers and the ambulance technicians and asks the police officers to bring the person to the nearest hospital emergency department with the assistance of the ambulance technicians. > If the condition or the behaviour of the person in crisis justifies restraining the person on a stretcher for his own safety and/or the safety of the police officer, the police officer may ask the ambulance technicians for help, and, if necessary, the person in crisis is taken by ambulance to an establishment as defined in article 6 of the Act, with the police officer on board if circumstances allow and justify this measure. > If the person accepts the support services that are offered after first refusing these services, the person is taken by ambulance to an establishment as defined in article 6 of the Act. In this case it is not necessary for the police officer to be on board the ambulance, however, the police officer may escort the ambulance to the establishment if necessary

27 3.2.1 PROCEDURES WHEN A PERSON IS BROUGHT TO THÉ HOSPITAL EMERGENCY ROOM, :, Whenever a person in crisis is brought to a hospital emergency department, the ambulance technician or the designated responder must call the emergency department staff (the assistant head nurse or the triage nurse) to warn them that a person is crisis is due to arrive. The information about the person in crisis is recorded by the designated responder when the assessment is made and sent by fax as soon as possible so that it may be included in the person's file. In every case in which a police officer rides on board the ambulance to accompany a person in crisis, the police office must unload his weapon and place it out of sight along with his supply of pepper spray, if applicable. In addition, the police officer must tell the person where he is being taken, advise them that they must submit to a psychiatric assessment, and advise them of their right to immediately call their family and a lawyer. When the designated responder takes a person in grave and immediate danger to the hospital with the person's consent, this person requires a safe environment and therefore this constitutes a medical emergency. The triage nurse immediately tells the doctor on duty in the emergency department that the patient's condition requires an urgent assessment that will probably call for the use of restraints or isolation. The doctor who is so advised will decide what measures to use. 9 This predicates that the establishment will act quickly to manage the case and that the designated responder will collaborate to facilitate this rapid take over and transmit the information to the person who takes over responsibility for the client. In addition, the hospitals agree to mobilize their staff in order that the designated responder may return to duty as quickly as possible. An awareness training programme will be launched to emphasize the importance of rapid action. Finally, the designated responder transmits the form entitled "Form for transmission of information in crisis situations 10 " to the staff of the establishment After the doctor has examined the patient, the establishment, with the patient's consent, sends the designated responder the information resulting from the process, i.e.: the doctor's decision about the projected treatment for the person who was brought to the there is a delay before the doctor can make the assessment, one possible measure that may be taken is to issue a personal verbal order to use restraints or any other measure deemed appropriate according to the condition of the patient. The position statement "Emergency Triage" published by the Collège des médecins du Québec in January, 2000, specifies, in Appendix 3, that a patient who is extremely agitated must be classified Level II - exceedingly urgent, and this classification means that the patient should be seen by the doctor within 15 minutes. A patient with acute psychosis with or without suicidal ideation will be classed as Level in - urgent, and should be seen by the doctor within 30 minutes.,0see Appendix5-20 -

28 emergency department, with the goal of ensuring continuity of service for the person in crisis. If the establishment admits the person under preventive confinement or interim confinement, the establishment must advise him where he is being held, the reason for this measure and of his right to immediately enter into contact with his family or a lawyer. Also, when the person leaves the hospital, the establishment must advise the person about the support services available in the community and/or refer the person to a CLSC or a community organization if required or pertinent In addition, if the Act applies and if the person has children under 18 years of age living with them, the designated responder or the police officer must ensure that the children are safe (call a friend or family member that can care for them) and must advise the Youth Protection Centre of the Laurentians regarding the case, if the safety of the children is or could be compromised. 3.3 REFERRALS TO THE CRISIS SHELTER «CENTRE D'HÉBERGEMENT DE CRISE LE SOLEIL LEVANT/CENTRE DU FLORES» > All referrals to the crisis shelter must be made by the designated responder from a CLSC or by a designated person from the emergency departments of the hospitals in Saint- Jérôme, Saint-Eustache, or Argenteuil, except with regard to known cases. > The requests can be made at any time (24/7), but in-person assessments and admission into the shelter take place between 8:00 a.m. and 8:30 p.m. during the week and between 11:00 a.m. and 6:00 p.m. on weekends. > The staff person from the crisis shelter can call the police to take the person in crisis to an establishment as defined in article 6 of the Act, if they determine that the person they have admitted is a grave and immediate danger to himself or to others, and the person refuses to cooperate. The police may be accompanied by ambulance technicians if necessary.

29 3.4 SPECIFIC AGREEMENTS WITH LE FAUBOURG SUICIDE PREVENTION CENTRE => With the coroner's office For postvention > When speaking with the bereaved people after a suicide, the coroner emphasizes the need for support and assistance in these circumstances. He gives them an information sheet for bereaved people, reassures them regarding the confidential nature of the services that are offered and contacts Le Faubourg Suicide Prevention Centre as soon as possible to forward the request for service if the people consent. > Once the suicide prevention centre receives the request, they contact the bereaved people by telephone with two (2) working days. During this call, the suicide prevention employee assesses the specific needs, offers certain services, or according to the need, refers the people to other pertinent resources. => With hospitals > After an attempted suicide and with the person's consent, the hospital refers the person to the suicide prevention centre so that the employee from the suicide prevention centre can follow-up with the person by telephone during a period of six months. > If the hospital's assessment indicates that the person has suicidal or other ideation, the hospital refers the person, with his consent, to the suicide prevention centre, so that the person can receive specific services from the suicide prevention centre. The hospital should also refer the friends and family who are aware of the situation, so they may also receive support and counselling from the suicide prevention centre. => With the police > With authorization from the suicidal person, the police officer speaks to the suicide prevention centre and gives them information about the suicide crisis.. > Following a request for intervention from a person who is a danger to himself or to others, the suicide prevention employee can call for the services of the ambulance and police to transport the person in crisis to an establishment as defined in article 6 of the Act. => With CLSC > These remain to be defined with the regional Info-Santé crisis support and postvention services

30 CONCLUSION It goes without saying, that successful inauguration of the Service agreements for cases of crisis and suicide depends upon the collaboration of all those who are involved at all stages of the procedure. This is why a training program to learn about and understand the service agreements is essential. This training also has the secondary objective of ensuring that everyone knows and recognizes the fields of expertise and training of everyone involved.. Joint action and communication are two basic elements that must be developed between the various intervening parties if we. are to have concordance, efficiency and improvement of the services we provide to highly vulnerable clients experiencing events beyond their control. The process of inaugurating the agreements will be monitored. The monitoring should ensure that the successful elements are identified, along with any obstacles, and that the pertinence of certain procedures is validated. In addition, the cross-sectorial groups in each territory should take the time to get together and pool their views regarding what is working and what is not working and to make adjustments to the service agreements

31 BIBLIOGRAPHY ASSOCIATION DES HÔPITAUX DU QUÉBEC (AHQ). La garde en établissement, Guide d'application de la Loi sur la protection des personnes dont l'état mental présente un danger pour elles-mêmes ou pour autrui, (1997, chapitre 75), Document de référence, juin BEAULIEU, Dominique. Loi sur la protection des personnes dont l'état mental présente un danger pour elles-mêmes ou pour autrui. L.Q., 1997, c.75. Document de référence. Pour la Régie régionale de Montréal-Centre, DIOTTE, M., DONATO, M.-A. et VAILLANCOURT, D. Entente de partenariat pour la crise et la crise suicidaire (document de base) - Territoire des Collines, mai DIOTTE, M., DONATO, M.-A. et VAILLANCOURT, D. Entente de partenariat - Territoire des Collines, L.R.Q., c. A-2.1. Loi sur l'accès aux documents des organismes publics et sur la protection des renseignements personnels, avril MINISTÈRE DE LA SANTÉ ET DES SERVICES SOCIAUX. Stratégie québécoise d'action face au suicide, S'entraider pour la vie, MINISTÈRE DE LA SANTÉ ET DES SERVICES SOCIAUX. Plan d'action pour la transformation des services de santé mentale, Québec, Direction de la planification et de l'évaluation, PROJET DE LOI N 39. La protection des personnes dont l'état mental présente un danger pour elles-mêmes ou pour autrui, 1997, chapitre 75. RÉGIE RÉGIONALE DE LA SANTÉ ET DES SERVICES SOCIAUX DE MONTRÉAL- CENTRE. Outil pour estimer la dangerosité et évaluer l'urgence, Document de travail, RÉGIE RÉGIONALE DE LA SANTÉ ET DES SERVICES SOCIAUX DES LAURENTIDES. Cadre de référence pour un réseau intégré de services d'aide en situation de crise pour les adultes des territoires J.-O. Chénier, Thérèse-de-Blainville, Arthur-Buies et Argenteuil conformément à la Loi 39, Document de travail, septembre RÉGIE RÉGIONALE DE LA SANTÉ ET DES SERVICES SOCIAUX DES LAURENTIDES. Mission 2002, Plan dé consolidation du réseau de la santé et des services sociaux des Laurentides , Les interventions auprès des clientèles,

32 RÉGIE RÉGIONALE DE LA SANTÉ ET DES SERVICES SOCIAUX DES LAURENTIDES. Plan d'action régional intégré pour les adultes en santé mentale (suicide), violence conjugale et sexuelle et toxicomanie (PARI), RÉGIE RÉGIONALE DE LA SANTÉ ET DES SERVICES SOCIAUX DES LAURENTIDES. Proposition d'organisation et de développement «Services intégrés d'aide en situation de crise et d'actions face au suicide» et modalités pour supporter son application, Document de travail, février RÉGIE RÉGIONALE DE LA SANTÉ ET DES SERVICES SOCIAUX DU BAS-SAINT- LAURENT. Réseau de services intégrés en intervention de crise, REGROUPEMENT DES CENTRES D'INTERVENTION DE CRISE DE LA RÉGION DE MONTRÉAL MÉTROPOLITAIN. Les centres d'intervention de crise : des partenaires dans le réseau des services de santé mentale, Document préliminaire, SÉGUIN, M., BOYER, R., BENOÎT, S., BOUCHARD, M., GIRARD, M.-E. Programmes de postvention : le point sur les modèles de postvention, juin VILLENEUVE, A., LAMOTHE, J.-G. Protocole d'intervention en situation de crise - santé mentale M.R.C. Domaine-du-Roy, CLSC des Prés-Bleus, Document de travail,

33

34 APPENDIX 8 MISSION, ROLE AND RESPONSIBILITIES OF THE VARIOUS RESOURCES THAT MAY RESPOND IN CASES OF CRISIS OR SUICIDE Each resource that intervenes in cases of crisis or suicide has defined their mission, role and responsibilities specifically to offer crisis-suicide services. The services described for each resource are not comprehensive and may differ slightly according to location or organization. These "sign cards" are designed to be a reference guide to provide the various partners with descriptions of the services of each of the resources involved in the service agreements. These descriptions can be added to or modified in accordance with what best describes each particular resource

35 Mission To offer shelter to adults in crisis from the four central and southern CLSC territories (Jean- Olivier-Chénier, Thérèse-de-Blainville, Arthur-Buies and Argenteuil), for a duration of several hours up to a maximum of fourteen days. Clientele Crisis shelter is for adults suffering from acute psychological distress or adaptational breakdown. Crisis shelter services are for people with diverse mental health problems and deal with both psychosocial crises and psychiatric crises. In every case, psychosocial help is required to meet the clients' needs, because the connection with each individual is established through words, and it is through these words that the intervention takes place. People in emotional distress and adaptational breakdown; People with suicidal ideation; People with mental health problems or serious and persistent problems; People with more than one problem (ex.: mental health problems and drug addiction). Role and responsibilities To intervene with people whose mental health is at high risk of deteriorating and/or if leaving the person at,home is a risk for the person or for their entourage; To explore the crisis situation, offer follow-up to defuse the crisis and encourage the development of strategies for change; Provide the client who uses the services of the shelter with post-shelter support services when needed; To gage if there is grave and immediate danger, including the risk of suicide, for the persons using the resource; Apply or collaborate in the application of Bill # 39, Chapter 75 when required; Promote continuity of services for the client (when needed) using an integrated approach with the employees of the public and community networks

36 GENERAL AND SPECIALIZED HOSPITALS With psychiatric departments Mission To provide general and specialized care including emergency, hospitalization and outpatient psychiatric clinic services. Role and responsibilities of the emergency department To receive the person at any time and ensure an immediate response to the person's need for assessment, treatment and referral; To have the emergency doctor or a general practitioner assess the level of danger; To provide adapted services : > physical and psychological, > psychiatric consultation, > 24/48 observation in the emergency department, > placement in preventive confinement, > order for confinement in an establishment, > therapeutic intervention, > psychosocial intervention, > evaluation of needs upon release from hospital, > referrals; To promote cooperation and joint action with the other resources in the community and the health and social services network partners. To apply or collaborate in applying Bill # 39, Chapter 75 when required; To promote continuity of services. Role and responsibilities of the Psychiatric departments Admission and global assessment of the clinical condition of the person by the health team; Evaluation of the degree of danger and control; To provide adapted services > assessment of bio-psycho-social needs, > specialized psychiatric services; > order for confinement in an establishment, > intervention plan, > planning for release from hospital (Individual service plan) according to the person's needs, > referrals To promote continuity of services

37 GENERAL AND SPECIALIZED HOSPITALS Without psychiatric departments Mission To provide general and specialized care for the population of their territory, including basic services such as emergency services and intensive care Role and responsibilities To receive the person at all times and to ensure the triage nurse handles the case immediately; To assess the person's needs and have the doctor on duty in the emergency assess the level of danger; To provide adapted services: > physical care; > request for psychiatric assessment; > preventive confinement > transfer to a hospital with psychiatric services; > referrals; To promote cooperation and joint action with the other resources in the community and the health and social services network partners. To apply or collaborate in applying Bill # 39, Chapter 75 when required; To promote continuity of services

38 LOCAL COMMUNITY SERVICE CENTRE (CLSC) U Mission To provide standard front-line preventive, curative, rehabilitation or reintegration health and social services to the population of their territories. Role and responsibilities To receive the person and their friends and families in situations of crisis and distress; To intervene in crisis situations (by telephone, in person or on the scene if necessary) and to assess the needs of the person, their friends and families. To defuse the crisis and help the person to develop strategies for change when possible; To provide services adapted to the needs that have been identified: > intensive crisis support, > accompaniment, > postvention, > post-trauma, > referrals; To gauge if there is grave and immediate danger on a local basis, including the risk of suicide; To apply or collaborate in applying Bill # 39, Chapter 75 when required; To promote cooperation and joint action with the other resources in the community and the health and social services network partners. To encourage the person's entourage to become involved by building upon the person's abilities and providing the necessary support; To promole continuity of services

39 LE FAUBOURG SUICIDE PREVENTION CENTRE & Mission Le Faubourg serves the entire population of the Laurentians. Le Faubourg's services are designed to attempt to prevent deterioration of the condition of people in situations of distress or in suicide crisis and to reduce the appearance and development of suicidal or homicidal ideas or behaviour. Clientele People with personal problems or who are in distress or crisis; People who are thinking about committing suicide or who have attempted suicide; People who believe that a friend or family member is thinking about committing suicide and who want to help; Anyone who wants to learn how to acquire the tools to practice preventive intervention or to intervene in suicide crisis situations; Any person who wants to learn more about the problem of suicide. Role and responsibilities Regional telephone hotline 24/7: reception, evaluation, suicide crisis intervention, orientation to other services if necessary; Postvention services for bereaved persons : individual, family, couple or group support meetings; Debriefing in the community : for groups affected by a suicide attempt or a suicide (families, friends, peers, schools, etc.); Post-crisis intervention (suicide); Ensure preventive follow-up for those who repeat suicide attempts for a 6-month period, with consenting individuals who are not receiving follow-up from another service; Telephone follow-up program with the police for suicidal clients; Follow-up program with the coroner for clients suffering a bereavement due to a suicide; Training and awareness programme for employees; Assessment of the risk of grave and immediate danger, including the risk of suicide; Apply or collaborate in applying Bill # 39, Chapter 75 when required; Promote continuity of services

40 REGIONAL INFO-SANTÉ Mission Regional Info-Santé provides bio-psycho-social crisis management response by telephone and tries to improve access to services and facilitate the process of orienting users within the health and social services network. The service is available to the entire population of the Laurentian region, and is for people who need information, referral/orientation or advice regarding health and social services. The service is also for people working in health and social services in the territory who need information about available resources for themselves or for their clients, or who need advice, orientation or a referral for their clients. Role and responsibilities Ensure there is a regional telephone access to a professional, outside of regular CLSC opening hours (8:00 p.m. to 8:30 a.m. Monday to Friday, and 4:30 p.m. to 8:30 a.m. on weekends and holidays) for: > bio-psycho-social reception, > evaluation, > information / advice, > orientation referrals; Ensure that clients are referred to the most appropriate resources to respond to their needs; Quickly provide all useful information about health and social services, and community services that are offered in territory, by updating the list of available resources; Intervene in crisis situations and assess the person's needs; Estimate if there is grave and immediate danger, including the risk of suicide; Apply or collaborate in applying Bill # 39, Chapter 75 when required; Promote continuity of services

41 Mission Provide general medical care to prevent the victim's condition from deteriorating and transport the victim to a health establishment as soon as possible. Role and responsibilities Receive calls directly from the emergency call service (ex.: 911); Assign the necessary resources at the scene; Identify potential risks and ensure that the people who intervene are safe; Approach the person in a calm and reassuring manner; Proceed with the prehospital clinical evaluation; Check if the person has injured himself, if there is a history of drug or alcohol abuse or medical problems, proceed to apply the appropriate medical protocol and transport the person with their consent; If the person refuses transport, refer to the police and if the police so request, help them transport the person to the hospital if the person is a grave and immediate danger to himself or to others; If possible and if pertinent, ask a friend or family member to meet the person at the hospital as soon as possible

42 POLICE SERVICES Mission Maintain peace, order and public security; Protect life and property; Prevent and représs crime and violations of law, find those who break the law and bring them to justice; Apply the laws in force in Quebec as well as municipal bylaws, resolutions and orders. Role and responsibilities Receive the initial call; Assign the necessary resources at the scene; Take information from witnesses and the family; Use an approach that is safe and establish a safety perimeter if necessary; Set up a way to communicate with the person; Engage in dialogue; Ensure confidentiality; Contact the designated resources already identified: CLSC, Le Faubourg suicide prevention centre, Regional Info-Santé; In conjunction with the ambulance service if necessary, ensure the victim is transported to a hospital; Apply the police policies in force with regard to the safety of people and property; Collect all noticeable facts about the person who is a danger to himself or to others so these facts can be recorded on pertinent documents approved by thé police force; Fulfill die obligation to advise the person as to where they are being taken, of the fact that they must submit to a psychiatric assessment, and that they can immediately call their lawyer and a friend or family member

43 APPENDIX 8 GLOSSARY THE CONCEPT OF CRISIS State of equilibrium : this is an active process as opposed to a fixed linear state. A person succeeds in maintaining a state of relative equilibrium to the extent that the adaptive mechanisms and means he uses succeed in eliminating the tensions that arise from various stress factors. Psychiatric crisis : this type of crisis is characterised by a certain loss of contact with reality caused by too much suffering. When the suffering becomes intolerable, the usual means of dealing with suffering become ineffective and the person cuts himself off from reality, which he mal-perceives or mal- interprets. Psychosocial crisis : By default, everyone lives in a state of equilibrium between day to day events and the means they have to cope with these events. Psychosocial crisis is the rupture of this equilibrium by a trigger in the person's life that the person perceives as a menace(job loss, divorce, loss of social status* illness,...). If the person's usual methods of coping with problems prove ineffective, the person can become disorganized or enter into a state of crisis. Suicide crisis : This crisis includes the same elements as the preceding types, but is characterized by a real or symbolic loss to the individual. This person is looking for solutions to questions and the solutions seem unproductive. Suicide becomes a possible alternative to relieve suffering and psychological distress. Suicidal ideation : the expression of suicidal thoughts or behaviour that is observed and that justifies the conclusion of intent to commit suicide although the act has not been accomplished. (Beaulieu, 1990). Suicide attempt : a situation in which a person's behaviour has put his life in danger with the intent of killing himself or demonstrating that such was his intent. (Beaulieu 1990). Completed suicide : all deaths where a deliberate life- threatening act resulting in death has been inflicted by a person against himself (Beaulieu 1990). Postvention : This term means all the support measures offered to people after a death by suicide, including support measures for families and friends, work and school communities and crisis intervention workers. Debriefing : This is a support activity intended to reduce acute stress and psychological aftermath that occur in people who have had a traumatic experience such as a natural disaster, a suicide, etc. Debriefing allows them to develop coping strategies that help them understand that stress is normal (and so reduce the stress)

44 THE CONCEPT OF GRAVE AND IMMEDIATE DANGER 1 Grave danger means any act, intention, threat, and any contemplated idea, that, due to a person's mental state: risks ending a life prematurely (the life of the person or of others); risks inflicting injuries that could seriously compromise safety or health (of the person or of others); risks exposing the person or others (intentionally or not) to a danger that threatens bodily security or life. Immediate danger means any act, intention, threat or contemplated idea that involves a grave danger to the life or health of the person or of others, and that has been recently acted upon (during the past few hours) or that is anticipated momentarily or within the next few hours. The short time frame involved in the execution of this act does not allow enough time to complete the procedure to obtain an order for a psychiatric evaluation without compromising the life or safety of the person or of others. SERVICE AGREEMENTS Service agreements are the links between the various partners (CLSC, hospitals, the suicide prevention centre, police departments, etc.,) that reinforce the coordination of all services offered to the same clientele. These agreements should support the application of the intervention protocols established by each of the resources, by facilitating access to the necessary services.. Everyone should know these means of coordination. INTERVENTION PROTOCOLS Each establishment, organization or resource that may provide services for people in crisis, their families or for persons suffering bereavement due to a suicide, should set up intervention protocols. These protocols should provide a better definition of responsibilities for those who intervene and ensure more efficient services. These intervention protocols should include the procedures of each resource, from the time the call for help is received to the time the client no longer uses the services. 1A modified version taken from appendix 1 of the Outaouais Service Agreements (2000)

45 APPENDIX 3 Request for help received by emergency call services* SITUATION # 1 # 2 # 3 # 4 # 5 # 6 With or without physical problem Acceptance or refusal of support \ services 41

46 Call for help received by the health and social services network APPENDIX 4 Community organization CLSC reception Establishment (CH, CR, CJ*) Assessment CLSC designated responder (by phone or in person) Info-Santé or CPS (by phone) Stays at home with support service Request order for psychiatric assessment Crisis shelter or follow-up by crisis service Hospital CLSC designated responder * Hospital, rehabilitation centre, youth centre Ambulance services Police services ** From 8:30 p.m. to 8:30 a.m. (weekdays) Other attendant (community organization, family, hospital employee) All dotted lines mean if necessary From 4:30 p.m. to 8:30 (weekends and holidays) * ** CPS: Le Faubourg Suicide Prevention Centre

47 APPENDIX 8 FORM FOR TRANSMISSION OF INFORMATION IN CRISIS SITUATIONS To standardize information records about crisis situations, a "Form for transmission of information in crisis situations" was adapted from the form used in the Outaouais region. In addition to transmitting information, the form is used as a guide in decision-making, and for background information to assist in the medical assessment when a person in crisis is brought to a hospital emergency department. In particular, this form should be completed when the person is referred either to a hospital or to a crisis shelter or other shelter. The second page of the form should be completed and sent by fax as soon as possible, to the workers who accompanied the person in crisis (police and/or designated responder) to ensure that the client benefits from continuity of service

48 Form for transmission of information in crisis situations in the Laurentians When the person's life, safety or health is in danger, or the life, safety or health of others is in danger.. lame : Address : elephone number : riend or family member : Telephone number : Date of birth : Scene of the intervention : Date : Time : lection to be completed by all responders Elements that served to trigger the crisis and the background of the intervention : Grave danger to life Planned suicide Planned homicide Threat of Dangerous behaviour (ex. : Russian roulette, etc.) Planning Means identified and available : _ Means identified but not available Selected place (where) : Chosen time : Past history of homicide or attempted homicide of attempted suicide of agression other Grave danger to safety Dangerous behaviour (ex. : crossing the road with eyes closed, wants to stay in a field in winter without shelter or equipment Apparent altered reality that causes the person to act in a threatening, impulsive, or unpredictable manner) : Threat of (ex. : setting fire) : Grave danger to health Dangerous behaviour (ex. : absorbs dangerous products ; diabetic refusing to take his insulin) : Self-mutilation (ex. : cuts himself) : Overdose with medications. Check with a medical source or Poison Control to see if the dose can be fatal. : Authorities : Poison Control : Other dangerous elements : (weapons) Agitated (ex. : seems incapable of self-control) Premises in a stale of deterioration or unsanitary Intoxication : alcohol, drags, medications or other Signature of responder : Signature of responder : Information obtained from the person himself Organization : Organization : other (specify connection to the person). Complete the orientation of the process (see overleaf) Section to be completed by the designated responders I' actors to consider to qualify the assessment TO Hallucinations : Q visual Q auditory j Significant thought disorganization (no hallucinations) 3 Total absence of food or sleep in the last 48 hours ' 3 Verbal aggression to others (in the past few days) J Other pertinent symptoms or information : Physical aggression to inanimate objects Altered judgement Very hlght level of anxiety Has stopped taking medication Social network : present non-existent exshausted comments. ignature of designated responder :.Resource :

49 Orientation of the Process