Medical Director's Position Paper: Repatriating Psychiatric Patients

Introduction

The scope of the problem:

Felkai et al. reported that 11.3% of travelers experience some symptoms of mental illness during travel, with 0.3% of travelers experiencing an acute psychotic episode and 1.2% require more than 2 months of therapy upon return from a trip abroad ¹. Middle-aged travelers (41-70 years of age) represent the largest group of those affected ². Steffen et al. reviewed medical reports for a large group of UN personnel over a 12-month period and found that 59% of those repatriated were for psychiatric illnesses (including alcoholism) ³. Military personnel represent a rather unique and large group amongst psychiatric patients scheduled for aeromedical transport, with Peterson et al. reporting psychiatric conditions as one of the leading reasons for the aeromedical evacuation of active-duty military personnel from the military combat theater ⁴.

Incidence data reveal that acute psychotic episodes account for one-fifth of travel-related mental illnesses⁵. Cumulative effects of travel-induced stress, culture shock, inappropriate alcohol intake and/or recreational substance use, circadian rhythm disruption, underlying brain pathology and physical illness have been implicated as contributing factors in the development of first-time psychosis during travel ⁶. Exacerbation of existing mental illness with acute psychotic episodes can be triggered by misuse of alcohol and/or psychoactive substances. In addition to drugs of misuse, certain medications used in travel medicine (such as mefloquine for malaria chemoprophylaxis) can potentially trigger acute psychotic episodes in people with a previous or undiagnosed mental illness.

Treatment of a patient with mental illness overseas poses several challenges including lack of or limited availability of mental health services or professionals in addition to language and financial barriers. Repatriation to the patient’s home country is therefore often the best option, usually carried out on commercial aircraft with medical escort or by dedicated air ambulance, depending on the patient’s medical condition.

Areas of concern:

There are several obvious areas of concern when transporting a patient with mental illness in the relatively confined environment of an aircraft. Safety and wellbeing of the patient, accompanying passengers and crew are key considerations before and during such a transport. Additionally, airports and aircraft are extremely safety conscious environments with high expectations on compliance in which irrational and potentially threating behaviors are poorly tolerated. Assessing, predicting and recognizing the risk for acute psychotic deterioration prior to and during a transfer is crucial to guarantee safety on board.

Legal uncertainty in non-consensual and involuntary cross- border transports does further complicate such transfers, with the possibility of either a loss of consent en-route or no consent from the onset of transport planning. Local law enforcement agencies may be involved. Appropriate and safe use of restraints and sedation may become necessary, which require expertise, training and well defined, robust protocols, while caring for the psychiatric patient may not be the core expertise of many air ambulance and commercial medical escort providers.

Finally, it may be difficult to ensure safe disposition with a safe chain of custody when there are barriers to readmission or the home situation has contributed to the patient’s behavioral problem.

Case Presentations

Case 1:

58 years old female. Diplomat with full diplomatic immunity. Unexpected deterioration of mental health status since arrival in a new Country. Diagnosed with acute bipolar episode and severe paranoid delirium. Ministry of Foreign Affairs and Embassy request urgent repatriation back to home Country.

Main complexities: unstable medical condition, volatile fitness to fly, repatriation on low-profile basis.

Consent from patient is waived, 21 years old daughter’s consent is secured. All stakeholders are continuously informed. Upon Air Ambulance arrival patient has deteriorated and needs to be sedated.

Local Country law does not allow treating a diplomatic patient against her will. Escort Doctor is not allowed to practice Medicine in the Country. patient finally gets sedated by local medical team after hours of talks and full official authorizations received.

Case 2:

29 years old expatriate male in remote Africa discovered with altered consciousness in his quarters with alcohol and drugs. Initial request by his manager to transfer him to Nairobi, Kenya. Patient has an extensive past medical history both personal and familial of mental health problems. Subsequent uneventful AA transfer to Nairobi to which the patient had consented both verbally & in writing. In Nairobi the initial evaluation showed a well oriented and coherent patient, who stated that he was coerced into providing consent and transferred against his will. The patient further expressed that he wanted to return to the site., which was not accepted by the treating psychiatrist. After several inpatient evaluations and discussions over a number of days, the patient agreed to an escorted commercial flight movement to the US. Upon arrival, the patient was admitted to a mental health facility. Legal proceedings were not pursued as deemed frivolous.

Case 3: 22 years old female on a foreign study program in Eastern Europe. After a public display of nudity in the city streets, admitted to a private medical facility where she was diagnosed with borderline personality disorder and self-harming behavior. Within 24 hrs she was to be transferred to a public institution for a minimum of 30 days where only the local language was spoken, followed by a tribunal. Immediate evacuation out of the country was advised and she was transported the next day by air ambulance to Skandinavia where she was admitted to hospital and commenced on therapy. The provider indicated she was fit to travel home on commercial aircraft under medical supervision, to be delivered into the hands of responsible family or readmitted. The patient was willing to return to North America but said that going to her immediate family would worsen her condition and thoughts of self-harm. Hospital acceptance for readmission was a challenge because she had no insurance for domestic health or psychiatric care. The repatriation was initiated with a physician carrying oral and parenteral sedation if needed and a nurse of the same gender as the patient. The treating facility refused to sign formal custody to the escorts citing no basis for involuntary custody. However, the patient consented to go in their company. The question of her becoming uncooperative en-route was left to the escorts to handle. Her travel insurance extended ex gratia additional funds for initial psychiatric hospital admission in her home country if necessary.

Case 4: 40 years old male soldier, admitted to the ICU for acute suicidal and homicidal tendencies. He was assessed as a ‘’high flight risk’’ by all involved. He was medicated and sedated with Diazepam/Promethazine; no physical aggression, just the repeated expression ‘’wanting to kill bad people with his weapon’’. The main concern was flight safety.

The mission was cleared, mostly for ethical reasons as the patient needed to be brought to a facility with higher/ specialized medical care. In view of his condition a number of adjustments were executed: the standard flight crew was increased from 2 to 3 medical staff: 2 flight nurses, 1 flight doctor. The interior of the aircraft was adjusted to ensure that there were no heavy, metal or sharp items available that could be used as a ‘’weapon’’ in case of inflight deterioration of the patient. Prior to the flight, the patient was briefed and informed in detail about all of the actions taken, the medical team successfully gained his trust and the mission was completed uneventful.

Logistical & Medical Considerations in the Transport of Psychiatric Patients

The main objective in the aeromedical transport of psychiatric patients is the safe repatriation with the patient managed without posing a threat to himself or others throughout the mission. Treatment options include non-pharmacological interventions, anti-psychotic medication and, for the acutely agitated patient, the use of restraints and or sedation.

It is important to recognize that psychiatric symptoms in patients with no provisional mental health diagnosis or past medical history of psychiatric disease, should be presumed to originate from a general medical condition until proven otherwise ⁷. As such, differential diagnosis needs to be comprehensive, to treat the primary medical condition that may be responsible for secondary mental health symptoms before an aeromedical transport is contemplated. Table 1 gives a non-exhaustive overview of medical conditions to be considered in patients presenting with psychiatric symptoms.

Risk Assessment / Scoring: Data suggest that violence is usually preceded by observable cues and behaviors, especially non-violent agitation ⁸. Although methods exist for clinicians to assess risk in agitated patients, there is no gold standard. More research correlating the available scores with stability for transfer, need for medical intervention, or need for restraints is urgently needed. While data on usability in aeromedical transfers is missing, a review of studies found the Agitation and Severity Scale (Table 2) to be acceptably reliable in assessing the degree of agitation in acute mental health patients presenting to the ED ⁹.

This 17-item checklist can be completed by a non-psychiatrist in 3–5 minutes, is reported to be simple, and does not require patient participation ¹⁰. The scale shows a good correlation with the slightly more complex and longer overt agitation severity scale (OASS, Table 3) ¹¹. Neither of the two scales has yet been validated in international aeromedical transport, and no cut-offs have been defined to identify need for restraints or sedation in transport.

However, the use of these or other standardized tools can enable the aeromedical team to conduct an objective assessment and prove invaluable in documenting the need for extended interventions, especially if conducted against the patient’s will.

Mode of Transport: Air Ambulance vs. Commercial Airline: Transport in an air ambulance aircraft can be tailored to the patient’s individual needs in terms of timing, personnel, and equipment. It also allows for proper monitoring and, if necessary, intervention in patients that require extensive sedation. In the extreme, critical care equipment does allow to transport a non-compliant patient intubated and ventilated. However, aeromedical patient transport utilizing commercial airlines are generally a more cost-effective alternative and is probably used for the majority of repatriations of patients with mental health issues. The IATA Medical Manual in its 12th edition does provide a framework for the medical acceptance of psychiatric patients on board commercial airlines. Patients suffering from chronic psychiatric disorders are accepted if controlled by medication and stable (i.e. living out in the community and taking care of all own needs including medication) while acute psychotic patients are only accepted on board if there was no episode within 30 days (e.g. mania, schizophrenia, drug induced) ¹². This clearly limits the possibility of repatriating patients with mental illness on commercial airliners to those with compliant behaviour and highlights the necessity of a reliable risk assessment prior to transport.

The ideal composition of the transport team for aeromedical psychiatric transports remains an area of uncertainty with little to no available data from systematic research. A person familiar to and trusted by the patient can have a calming effect on an agitated patient and could be added to the transport crew, such as the frequently employed “battle buddy” in the transport of military personnel with mental health problems ¹³. A medical escort of the same gender as the patient can support a more effective surveillance (i.e. during bathroom visits) and circumvent the accusation of perceived sexual harassment, however, literature suggests that same-sex aggression in psychiatric patients exceeds aggressive behavior towards the opposite gender ¹⁴. If physical aggression is considered a realistic possibility, it may be advisable to have two escorts with the physical capability to restrain the patient until de-escalated.

Non-pharmacologic Interventions: The initial approach to a patient with agitation should always start with verbal de-escalation, environmental modifications and other strategies that focus on the engagement with the patient and not on physical restraint. Moskovitz et al. point out the potential in using telepsychiatry to de-escalate, which might be particularly helpful in international repatriation in which local psychiatric interventions could be limited due to language barriers ⁹.

Antipsychotic Medication: Antipsychotics have been extensively used for the treatment of acute agitation. Amongst these, second generation antipsychotics have been recently recommended over haloperidol either alone or in combination for agitation due to a psychiatric illness. Olanzapine is probably the best studied oral second generation antipsychotic and was used with convincing effect and safety in doses of 5–20 mg/day as well as up to 40 mg/day in several studies ^15,16.

Sedation: Using antipsychotics and benzodiazepines – whether a single agent or combined – will have similar efficacy in producing sedation, but there are differences in the time to sedation depending on which agent is used. Based upon the available studies, droperidol (5–10 mg IM) and midazolam (5–10 mg IM) have the fastest onset of sedation when either is used as a single agent ¹⁷. When combination therapy is used, using midazolam with an antipsychotic agent, instead of lorazepam, may result in faster sedative effect ¹⁸.

While Ketamine has been increasingly recognized as a safe and effective sedation during aeromedical retrieval of psychiatric patients due to its very rapid onset of action (3-5 min), it is often reserved as a second-line agent when antipsychotics and benzodiazepines fail to produce the desired tranquilization ^19,20. High dose ketamine (5 mg/kg IM) is more frequently associated with airway compromise requiring endotracheal intubation. A low dose of ketamine (2 mg/kg IM) may reduce the risk of airway compromise while providing adequate sedation.

Use of Restraints: Physical restraint should only be used as a last resort strategy when it is the only means available to prevent imminent harm, while relevant legal considerations need to be taken into account. During transport by motor-vehicle or aircraft, seatbelt like restrains with a buckle guard that does allow opening only with a pin or key may serve in a double function and provide safety for crew and passenger. Restraints must not hinder the ability to monitor the patient’s wellbeing and vital parameters and allow quick and effective access for the treatment of any unforeseen emergency such as aspiration, ventilatory compromise and/or circulatory deterioration, amongst others. Obviously, restraint of patients should be individualized and used in a manner that makes all reasonable attempts to maintain the patient’s privacy and dignity. The need for emergency evacuation of the aircraft / vehicle also needs to be considered.

Patient Disposition: Finally, it is especially important in effecting transportation of a psychiatric patient to ensure a safe disposition and hand-off. When decisional capability or inability to travel independently requires a medically supervised transport, it must be assumed that the patient is not necessarily safe to be released on their own recognizance. The decision on final disposition upon arrival will depend on the assessment of the on-site provider as well as other associates, the impression of the transporting team, the cooperation of family or other entity available to take over responsibility upon receipt, and the effect of removing the patient from the overseas environment that presumably incited or exacerbated the condition. Challenges that often complicate the handover plan are inability to secure psychiatric hospital readmission, uncooperative family or other complicated home factors that may have contributed to the patient’s behavioral issues.

Legal Considerations in the Transport of Psychiatric Patients

Mental capacity: When dealing with acute psychiatric illness or psychotic episode, the starting point for every patient is to assume that they have capacity until it is established that they do not. The question of capacity is usually decided by the treating medical team in the patient's current location. Each jurisdiction has its own definition of capacity and deals with the consequences in their own way. A court may need to determine whether someone can be deprived of their liberty despite their lack of capacity.

Each case needs to be looked upon on its own facts. Consideration needs to be given to both, the laws of the patient's current location and that of their "habitual residence". The courts in the majority of the EU and North America and elsewhere around the developed world would not consider that a patient's habitual residence changed simply by going on holiday. If the patient decided to work or live somewhere else, then the habitual residence can change. Once the patient has been repatriated, there can be no assumption that any decision as to capacity taken abroad would be recognized.

Definition of capacity: The definition in the UK from the Mental Capacity Act 2005 ²¹, defines capacity as follows: “A person lacks capacity in relation to a matter if at the material time they are unable to make a decision for themselves in relation to the matter, because of an impairment of, or a disturbance in the functioning of, the mind or brain.” We have some guidance as to the ability to make a decision:

• understand the information relevant to the decision;
• retain that information;
• use or weigh that information as part of the process of making the decision;
• or communicate their decision (whether by talking, using sign language or any other means).

When liberty can be deprived: A foreign legal system may order the return of a patient. There are many cases where foreign courts have ordered the return of an incapacitated adult from abroad. It is reasonable to assume that the court in the current location of the patient will invariably be able to decide in the best interest of the patient, whether that be for repatriation immediately or following a short stay in an appropriate institution. It is important to review the facilities that are available to the patient. There should be no assumption in the preference of returning the patient to their family, although that is often the best course of action. The Courts can be critical of legal and medical professionals being overly protective of a vulnerable patient (the protectionist culture), which can make it very hard to decide the correct course of action. If a court were to consider the matter, they would balance a necessary and appropriate course of action and whether it properly justified interference with the rights of a patient (for example by ECHR art8) ²².

Treatment involving Chemical or Physical Restraint: There is some helpful guidance as to when restraint becomes a deprivation of liberty, but each case must be decided on its own merits. Where the patient's treatment is considered according to the laws of the UK, restraint may be used and does not amount to deprivation of liberty where:

• Restraint is necessary to prevent harm to the patient and others
• Restraint is a proportionate response to the likelihood of a patient suffering harm and the seriousness of that harm

The code of practice published by the Ministry of Justice (MOJ) on the Mental Capacity Act 2005 ²³concluded that:

• Laying hands on someone to lead them into a vehicle for the purposes of a journey, belting them into the vehicle and locking the door during the journey would not amount to a deprivation of liberty.
• Placing the person in a restrictive hold to get them into a vehicle, hand or leg cuffing them and restricting their movement during the journey would amount to a deprivation of liberty.

Department for Health and Social Care (DHSC) guidance ²⁴stated that:

• ’The Department believes it would be very rare for there to be a deprivation of liberty when transporting a patient in an ambulance or another vehicle for the purposes of care and treatment. ’
• ‘Restrictions imposed while transporting a person who lacks capacity would nearly always be covered by the MCA.’
• ’Legal advice may be required in respect of a particularly long journey during which significant restraints and restrictions are in place.

Note that an acceptable means of restraint varies between jurisdictions and will depend on the patient's condition and environment.

Roles and Liabilities during Aeromedical Transport: The aircraft commander has power to ensure law and order on board his aircraft. The captain ought to be able to act appropriately and take reasonable measures to restrain a passenger with consideration for the safety of the staff and crew in close teamwork with the treating medical team and medical escorts.

The UK's Civil Aviation Authority has given some guidance focused around the question of whether the condition may interfere with the safe conduct of the flight or if the flight environment may exacerbate the condition ²⁵. IATA and the US' Federal Aviation Administration provide guidance as dealing with restraining an unruly or dangerous passenger ¹².

Treatment provided by a medic not correctly registered in a particular nation could be a crime in that nation, or they may not have a particular permit/visa allowing them to practice. When flying, it is the jurisdiction of the aircraft that governs law for treatment provided within the aircraft. One possible solution for this problem would be a tarmac hand- over of the patient with the medical team staying on board whilst the patient is brought onto the plane. However, when someone is critically ill, there is a need for continuity of care and a bed-to-bed care by one medical team is advised. Other workarounds could include the “pro-forma” presence of a locally registered paramedic /nurse on the ground ambulance together with the foreign transport team. While signed informed consent, stating that the patient wishes to be transported and treated by this specific practitioner despite local registration status may be used in patients with capacity, one needs to keep in mind that for a patient with limited capacity the ability to consent is also limited.

Powers of Attorney and Guardianship: It is worth checking whether the patient has granted Lasting Power of Attorney to a third party to make health and care decisions. Often patients will have a lasting power of attorney in place that becomes effective at the point a patient loses capacity, as they tend to be drawn at the time a patient wrote their Will. Where the patient lacks capacity, instruction can be obtained from the attorney named in the document. Note that it must be a lasting Power of Attorney as an ordinary Power of Attorney is only valid whilst the patient has capacity. Guardianship can be arranged in a patient's absence, the process for which varies between jurisdictions, but usually a judge will make the decision on the basis of expert psychiatric evidence.

Conclusions and Recommendations

Psychiatric cases remain some of the most demanding and unpredictable challenges in aeromedical repatriation. In addition to medical and logistical considerations, legal obstacles further complicate such missions. With psychiatric illnesses (including alcoholism) being amongst the most common reasons for assistance abroad and repatriation, it comes as no surprise that awareness and training in travel psychiatry and acute mental health interventions amongst aeromedical practitioners and medical personnel in assistance companies is increasingly advocated ^13,26. The European Aeromedical Institute (EURAMI) reacted to this call and has provided a dedicated accreditation standard with a special endorsement for organizations that provide robust protocols and training for the transport of patients with mental illness ²⁷.

We identified the following key components as key performance indicators for a high- quality international repatriation of a patient with a psychiatric condition:

• Extensive differential diagnostic work-up for (treatable) organic origin of symptoms.
• Consideration of local diplomatic and legal limitations for medical care.
• Documented communication with treating medical team, patient, family and, if applicable, local law enforcement, in the planning phase of the transport.
• Documented and repeated standardized assessment of risk for in-transport psychotic deterioration.
• Training of the transport team in verbal de-escalation.
• Pre-planned and documented escalation plan towards the use of restrains and sedation by trained personnel.
• If necessary, use of individualized restraint in a manner that makes all reasonable attempts to maintain the patients’ privacy and dignity.
• Frequent/continuous monitoring of restrained and/or sedated patients with a documented periodical re-assessment of the need for restraints and / or sedation.
• Careful planning for final disposition and, if necessary, chain of custody of the patient.

Cooperation of the patient and voluntariness of the decision to be repatriated is obviously always preferable to a deprivation of liberty when transporting a patient with a psychiatric diagnosis. If chemical and/or physical restraints need to be used, avoidance of harm is a useful guiding principle. Access to a legal counsel for a (documented) pre-transport discussion and decision may be helpful to reduce uncertainty for the transport team.

Adapted from Yudofsky et al.¹¹