Seclusion, Restraint,

Right of patient, matters

of communication & ECT
Sim Su Tein
• Power to make regulations

• 92. (1) the minister may make such regulations as

appear to him to be necessary or expedient for
carrying out the provisions of this act.

• (2) without prejudice to the generality of the powers

conferred by subsection (1) regulations may be made
for all or any of the following purposes:

• (a) to prescribe the forms and certificates to be used

for the purposes of this act;
• (J) to prescribe the conditions and circumstances
under which physical and chemical means of
restraint or seclusion may be applied to persons
detained in psychiatric hospitals;
 Restraint & Seclusion

• Indication and procedure for restraint or seclusion

• 25. (1) The indications and procedures for physical

or chemical means of restraint or seclusion may be
applied to patients detained in psychiatric
hospitals shall be as specified in the Third
Schedule.
 Restraint & Seclusion

• Indication and procedure for restraint or seclusion

• 25. (1) The indications and procedures for

physical or chemical means of restraint or
seclusion may be applied to patients detained in
psychiatric hospitals shall be as specified in the
Third Schedule.
 Indications (Restraints)
Chemical Restraint Physical Restraint

• A. Indication for chemical means of • C. Indication for physical means of

restraints restraint

• (1) The restraints are for the purpose • (1) A restraint is for the purpose of
of the medical treatment of the the medical treatment of the patient.
patient.
• (2) To prevent the patient from
• (2) To prevent the patient from causing injury to himself or any
causing injury to himself or herself or other person.
any other person.
• (3) To prevent the patient from
• (3) To prevent the patient from persistently destroying property.
persistently destroying property.
• (4) When other less restrictive
• (4) When other less restrictive method of treatment to calm the
method of treatment to calm the patient has not been successful.
patient has not been successful.
 Indications (Seclusion)

• G. Indication for seclusion

• (1) A patient in a psychiatric hospital may be kept

in seclusion only if it is necessary for the protection,
safety or well-being of the patient or other persons
with whom the patient would otherwise be in
contact.

• (2) Other less restrictive method of treatment to

calm the patient has not been successful.
 Restraint & Seclusion

• Indication and procedure for restraint or seclusion

• 25. (1) The indications and procedures for

physical or chemical means of restraint or
seclusion may be applied to patients detained in
psychiatric hospitals shall be as specified in the
Third Schedule.
 Procedures of Restraint (Third Schedule)
• B. Chemical Restraint • D. Physical Restraint

• (1) Approved chemical means of • (1) Approved physical means of restraint

restraint
• (a) The medical officer or registered
• (a) The medical officer or registered medical practitioner shall approve the
medical practitioner shall prescribe form of physical means of restraint.
the drug to be administered.
• (b) In the case of an emergency, the
• (b) In the case of an emergency, the psychiatric nurse on duty shall be
medical officer or registered medical authorised to administer any form of
practitioner shall authorise the nurse physical means of restraint.
or medical assistant on duty to
administer the drug. • (c) The form of physical means of
restraint administered by the
• (c) The nurse or medical assistant psychiatric nurse on duty shall be
on duty shall notify to the medical notified to the medical officer or
officer or registered medical registered medical practitioner without
practitioner the drugs administered. delay.

• (2) Consent for chemical means of • (2) Consent

restraint
• It shall not be necessary to obtain a
• Consent shall be obtained from a person’s consent to the application of
voluntary patient prior to chemical physical means of restraint.
means of restraint
 Procedures of Restraint (Third Schedule)
• B. Chemical Restraint • D. Physical Restraint

• (3) Care of the patient under chemical • (3) Care of the patient during physical means of
means of restraint restraint

• (a) If the patient is acutely disturbed, a • (a) No physical restraint is allowed in the
member of the nursing staff shall visit at psychiatric nursing home and community
15 minutes interval. mental health centre, EXCEPT at the time
of transportation of patients to a
• (b) A medical officer or registered psychiatric hospital.
medical practitioner shall examine the
acutely disturbed patient at intervals of • (b) If the patient is acutely disturbed, a
not more than 4 hours. member of the nursing staff shall visit at
intervals of not more than fifteen minutes.
• (c) The vital signs of the patient shall
• (c) A medical officer or registered medical
be monitored frequently as ordered
practitioner shall examine the acutely
by the medical officer or registered
disturbed patient at intervals of not more
medical practitioner.
than four hours.
• (d) The patient shall be supplied with • (d) The patient shall be supplied with
bedding and clothing at appropriate bedding and clothing at appropriate times.
times.
• (e) The patient shall be provided with
• (e) The patient shall be provided with adequate toilet facilities.
adequate toilet facilities.
• (f) The patient shall be provided with food
• (f) The patient shall be provided with and drinks at the appropriate times.
food and drinks at the appropriate times
 Application of physical means of restraint

• 28. The physical means of restraint of patients shall

be –

• (a) carried out or supervised by qualified, trained

and experienced personnel; and

• (b) applied only to the limbs of a patient.

Procedures of Restraint (Third Schedule)

• (4) Removal of physical means of restraint

• (a) Decision to remove the restraints shall be made

by the psychiatric nurse on-duty.

• (b) The medical officer or registered medical

practitioner must be informed of the termination of
restraints.
 Procedure for Seclusion (Third Schedule)
• H. Procedure for seclusion

• (1) The use of seclusion shall be authorised by the medical officer or registered medical practitioner.

• (2) In the case of an emergency, the medical officer or registered medical practitioner may authorised the psychiatric
nurse or medical assistant to keep patient in seclusion for a period of time specified in the authorisation and notified
medical officer or registered medical practitioner of such seclusion without delay and medical officer or registered
medical practitioner shall review the patient as soon as practicable.

• (3) It is not necessary to obtain a person’s consent for his seclusion to him or her.

• (4) A member of the nursing staff shall visit an acutely disturbed patient at intervals of not more than fifteen minutes.

• (5) A medical officer or registered medical practitioner shall visit the patient under seclusion at intervals of not more
than four hours.

• (6) The patient shall be supplied with appropriate bedding and clothing at appropriate times.

• (7) The patient shall be provided with adequate access to toilet.

• (8) The patient shall be provided with food and drinks at the appropriate times.

• (9) The patient may request to communicate with others while under the seclusion.

• (10) The decision to terminate the seclusion may be made by the medical officer or registered medical practitioner.
• (2) No minor patient below the age of twelve shall be subjected to
physical means of restraint or seclusion in psychiatric hospitals.

• (3) The privacy and safety of a patient shall be observed at all times
during the restraint or seclusion procedures.

• (4) No physical or chemical means of restraint or seclusion shall be

applied to patients in any psychiatric nursing home or community
mental health centre, except during an emergency and the patient
shall then be transferred to psychiatric hospitals without delay.

• (5) If the period of physical means of restraint of a patient exceeds eight

hours, a psychiatrist shall review the patient on the need for further
restraint.

• (6) No seclusion shall be carried out on a patient for more than eight
hours consecutively or for more than twelve hours intermittently
over a period of forty eight hours, without an independent review by a
psychiatrist or any other medical practitioner of similar seniority who was
not directly involved in the care of the patient at the time of the incident
which led to the seclusion of such patient.
Restraint Area Seclusion Room
• 29.

• (1) There shall be a dedicated single seclusion room manned by a

qualified, trained and experienced staff for the purpose of seclusion of
patient.
• 26.
• (2) The seclusion room shall be –

• (1) There shall be a • (a) adequately lit and ventilated;

designated restricted area • (b) located to maintain privacy and monitoring of patient;

with a dedicated • (c) of a minimum dimension of 10 square meters;

observation bay manned • (d) provided with physically permanent partition; and

by a qualified, trained and • (e) adequately sound proof.

experienced staff for the • (3) The door of the seclusion room shall:

purpose of monitoring of • (a) be a single outward opening door made of sturdy material;
and
patients.
• (b) have an observation panel made of safety glass.

• (2) The area referred to in • (4) The furnishing in such room shall be made of material that
will not endanger patient.
subregulation (1) shall be • (5) Such room may have closed circuit television monitoring.
adequately lit and
• (6) Cages, wooden box, iron bars, grills or metal traps or other
ventilated. demeaning container or compartment shall not be used as
means of seclusion of patient in such room.
 Restraint Equipment
• 27. The equipment allowed or prohibited to be used as physical
means of restraint of patients shall be as specified in the Third
Schedule.
• E. List of equipment prohibited to be used as
physical means of restraint: • F. List of equipment allowed to be
used as physical means of restraint:
• (1) Strings, ropes and raffia;

• (2) Handcuffs, shackles and ―pasung‖;

• (1) Restraint bed;

• (3) Body restraint; • (2) Restraint chair;

• (4) Strait jacket;
• (3) Padded restraints made of either
• (5) Chains (from whatever material); calico cloth or cotton , leather ,
nylon, vinyl , polyurethane, silicone
• (6) Wire;
or rubber based materials; and
• (7) Bandage; and
• (4) Any other equipment approved
• (8) Equipment with tears, protruding metal by the Director General.
parts or any defect that may endanger patient.
Information to be kept in record
• 30.

• (1) Every restraint area or seclusion room shall maintain

record containing information as specified in the Third
Schedule.

• (2) The record kept in the restraint area and the

seclusion room shall be called the Physical Restrain
Record and the Seclusion Record respectively.

• (3) Both Records shall be made available at all times

for the purpose of inspection.
 Information to be kept in a record

• Chemical restraint
• Physical restraint

• (5) Information to be recorded by the

• (4) Information to be recorded by the
medical officer or registered medical medical officer or registered medical
practitioner practitioner

• (a) The indication for the restraint. • (a) The drug and mode of admission for
chemical means of restraint used.
• (b) The form of physical means of restraint
used. • (b) The indication for the restraint.

• (c) The name and signature of the person • (c) The name and signature of the person
who approved or authorised the use of that who approved or authorised the use of that
restraint. restraint.

• (d) The name and signature of the person • (d) The name of the person who
who applied the physical means of restraint. administered the chemical means of
restraint.
• (e) The name and signature of the person
who authorise the removal of the physical • (e) The time of administration of chemical
means of restraint. means of restraint.
• (f) This information shall be recorded in the • (f) This information shall be documented in
patient’s record.
the patient’s record.
 Third Schedule
• I. Information to be included in the Physical
Restraint Record: • J. Information to be included in the Seclusion
Record:
• (1) The following particulars of patient:
• (1) The following particulars of patient:
• (a) Name;
• (a) Name;
• (b) Age;

• (c) Sex; and

• (b) Age;

• (d) Identification Number. • (c) Sex; and

• (2) Reasons why physical means of restraint was • (d) Identification Number.
used.
• (2) The indications for seclusion.
• (3) Name and signature of the person who
approved or authorised the use of physical means • (3) The name and signature of the person who
of restraint.
authorized the use of seclusion.
• (4) Name and signature of the person who
monitors the patient restraint. • (4) The name and signature of the person who
monitors the patient in seclusion.
• (5) The period of time for which the patient was
kept in restraint. • (5) The period of time from the beginning to
the end for which the patient was kept in
• (6) List of injuries and complications sustained seclusion.
during the physical restraint
Right of Patient
 Statement of Patient's Right
• 43. (1) The Medical Director or licensee or person in charge, as the case may be, of a psychiatric
facility shall provide statement of patient’s rights as may be approved by the Director General.

• (2) The statement of patient’s rights shall be in a manner and language in which patient’s relatives or
friend understands.

• (3) The statement of patient’s rights shall contain at least the provision for the rights of patients to –

• (a) the reasons of his admission and detention and means of discharge, leave or transfer;

• (b) treatment, information, confidentiality, personal identity and privacy;

• (c) adequate accommodation;

• (d) recreational activities;

• (e) practice gender identity;

• (f) practice religious belief of his choice;

• (g) communicate with persons outside;

• (h) receive visitors;

• (i) have access to a second psychiatric opinion;

• (j) obtain legal representation; and

• (k) appeal to the Medical Director, the Board of Visitors or the Director General for discharge.
Duty to provide statement of patient's rights

• 44. (1) The Medical Director or licensee or person in charge of a

psychiatric facility, as the case may be, shall provide the statement
of patients’ rights to every patient in the psychiatric facility.

• (2) Notwithstanding subregulation (1), where the patient is unable

to comprehend the meaning of the statement of patients’ rights
due to reason of his state of mind, the statement of the patients’
rights shall be provided as soon as the patient becomes capable
of comprehending the meaning.

• (3) The statement of patients’ rights shall be kept at a place readily

accessible and available to all relatives or friend of patients and
staff involved in the treatment and management of patients in a
psychiatric facility.
Statement of patient's right to be exhibited

• 45. The statement of patients’ rights shall be

exhibited in a conspicuous part of the psychiatric
facility.
Documents to be made available for reference

• The Medical Director or licensee or person in

charge, as the case may be, of a psychiatric facility
shall make available documents as specify in the
Fourth Schedule for reference by patient, or his
relatives or friend in the psychiatric facility.
 Fourth Schedule
• Documents to be made available at a psychiatric
facility

• (1) Mental Health Act 2001;

• (2) Mental Health Regulations 2010;

• (3) National Mental Health Policy; and

• (4) Patient’s information sheet on the statement of

patients’ rights.
 Matters of
Communication
Communication by patient admitted or detained in
psychiatric hospital

• (1) A letter written to or by a patient admitted or detained in a

psychiatric hospital shall be forwarded without being opened to
the person to whom it is addressed.

• (2) At least one telephone and line shall be provided on each floor
of a psychiatric hospital for use by patients for either incoming or
outgoing calls and such telephone shall be located at a place that

• (a) easily accessible to the patients; and

• (b) ensures privacy of communication to the patients.

• (3) Other forms of communication shall be provided for as may be

directed by the Director General.
 Communication by person detained or
confined in approved psychiatric hospital
• 48. (1) Subject to subregulation (2), any person detained or confined
under section 342, 344 or 348 of the Criminal Procedure Code [Act 593]
or corresponding provisions in any other written law in an approved
psychiatric hospital may have unintercepted access to communication.

• (2) The Medical Director or person in charge, as the case may be, of an
approved psychiatric hospital may if deemed necessary subject any
letter written by or to any person detained or confined there for scrutiny.

• (3) All correspondence by letter to and from the counsel, elected

representative or Ruler’s Office of the detained or confined person shall
not be intercepted.

• (4) The Medical Director or person in charge, as the case may be, of an
approved psychiatric hospital may impose such security conditions for
the use and location of the telephone on any person detained or
confined in the approved psychiatric hospital.
Electroconvulsive
Therapy
 Procedure

• 20. The decision to initiate electroconvulsive

therapy and the number of treatment sessions on
any patient in any psychiatric hospital shall be
made by a psychiatrist.
 Operation theatre or treatment suite
• 21. (1) Subject to subregulations (2),(3) and (4), the Medical Director or licensee of a psychiatric hospital shall
ensure that all electroconvulsive therapy on any patient is conducted in an operation theatre or treatment suite
of the psychiatric hospital by a psychiatrist or a medical officer or registered medical practitioner under the
supervision of a psychiatrist.

• (2) The operation theatre or treatment suite referred to in subregulation (1) shall have a dedicated waiting,
treatment and recovery rooms or area.

• (3) The rooms referred to in subregulation (2) shall be–

• (a) adequately lit and ventilated; and

• (b) adjoining and connected to each other.

• (4) The operation theatre and the treatment suite shall not be used as traffic flow.

• (5) The treatment room in either the operation theatre or the treatment suite shall have a –

• (a) minimum dimension of 16 square meters; and

• (b) dedicated area for electroconvulsive therapy equipment, supplies and records.

• (6) The Medical Director or licensee of a psychiatric hospital shall ensure that the recovery room or area, in the
operation theatre or the treatment suite have a dedicated staff with the relevant qualification, training and
experience.

• (7) The Medical Director or licensee of a psychiatric hospital shall maintain patients register for the operation
theatre or the treatment suite.
 Oxygen supplies in treatment and recovery rooms or area

• 22. The oxygen supplies in the treatment and recovery

rooms or area of the operation theatre or treatment
suite shall be adequately monitored and recorded in a
logbook.
Equipment and supplies in the treatment room

• 23. The Medical Director or licensee of a

psychiatric hospital shall ensure that a treatment
room of a psychiatric hospital is equipped with
minimum equipment and supplies as specified in
the Second Schedule.
 Second Schedule
• A. Minimum requirement of equipment in the electroconvulsive therapy suite

• (1) Electroconvulsive therapy device;

• (2) Device for monitoring the electrocardiogram (ECG);

• (3) Device for monitoring blood pressure;

• (4) Oxygen delivery system capable of providing intermittent positive pressure oxygen by
mask or endo-tracheal tube;

• (5) Intubation set with airways (assorted sizes);

• (6) Suction apparatus;

• (7) Defibrillator;

• (8) Pulse oxy-meter; and

• (9) Emergency drug trolley with a list of emergency drugs

Electroconvulsive therapy device, maintenance and
logbook

• 24. (1) The Medical Director or licensee of a psychiatric

hospital shall ensure that the electroconvulsive therapy
device used to deliver the electrical stimulus on the patient
complies with requirements as specified in the Second
Schedule.

• (2) The electroconvulsive therapy device shall have regular

maintenance according to the manufacturer’s guidelines
and all maintenance activities, test results, deficiencies and
corrective measures shall be documented in a logbook.

• (3) The logbook shall be kept in the treatment room and be

available at all times for inspection.
 Second Schedule
• B. Electroconvulsive therapy device and testing

• (1) The electroconvulsive therapy device should conform to applicable device

standard.

• (2) The electroconvulsive therapy device shall be –

• (a) tested prior to first use for output characteristics and operation of all
controls, parameters, and features;

• (b) calibrated by qualified personnel;

• (c) Provided with a description of testing procedures and preventative

• maintenance instructions; and

• (d) functioning according to device standards.

Thank you