ethics grand rounds: dilemmas in psychiatric care
TRANSCRIPT
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Ethics Grand Rounds: Dilemmas in Psychiatric Care
Presented by Andrea Chatburn, DO, MAMedical Director for Ethics
9.29.2015
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www.providence.org/ethics
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Objectives
Review and Discuss:• Moral Distress in Caregiving• Refusal of medical interventions• Involuntary psychiatric treatment• Psychiatric Advance Directives & Ulysses
Contracts• Confidentiality• Limits of confidentiality
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Conflicting Values Moral Distress
• Government, representing society’s interests
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Refusal of medical interventions:
Patients who have medical decision making capacity are allowed to be refuse recommended medical interventions and make what may seem like unreasonable or even harmful choices.
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However:
• Severe symptomatic Psychiatric illness may impair the patient’s expression of autonomy• Psychiatric treatment may restore
autonomy • Goal: harm reduction
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Capacity- Medical
Capacity is both specific and dynamic. Specific Question Specific Time Dynamic- can change based on time and
question
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Capacity- Medical
Requirements for Medical Decision Making Capacity: Choose & Communicate that Choice Must understand relevant information &
appreciate medical consequences Teach back
Reason Through Options- Risks/Benefits Consistent with known values
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Competence- Legal
Adults assumed competent Incompetence determined by a court Global- unable to make any decisions Need for referral to attorney with goal of
naming a Guardian ad Litem Guardian
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Involuntary Psychiatric Treatment
• WA State: Designated Mental Health Professional (DMHP)– Danger to self, others– Gravely Disabled• Serious harm resulting from inability to care for self, ex:
food clothing, shelter.• Severe deterioration in routine functioning (repeated,
escalating loss of control over actions, not receiving care required for health and safety)
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Voluntariness
• Even if the patient qualifies for involuntary detainment, if they are deemed to have capacity and are voluntarily willing, must obtain informed consent.
• Informed consent must be free from coercion• Patient must actually have a choice to make–Poverty confounds this–Accessible mental health 24/7?
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Potential Abuses of Involuntary Treatment
• Utilization of psychiatric detainment for political gain (patients who don’t meet state criteria for detainment)
• Mistreatment of patients during the involuntary admission– Food, water, shelter, clothing– Free from verbal, emotional, physical abuse– Proportionate use of restraints
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Least Restrictive Alternative
Short term violation of freedom Typically outpatient treatment History of ongoing threat to safety of self or
others due to psychiatric illness “least restrictive” is a negative goal
medicine strives for positive goal of reduced suffering and improved functioning.
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Outpatient involuntary treatment
May occur when:• Guardian may decide- “best interest”• Conditional release from correctional
institution• Court mandated tx in lieu of incarceration• “Assisted Community Treatment”- Outpatient
commitment. Ex: Washington D.C.
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Refusal of medical interventions:
Patients who have medical decision making capacity are allowed to be refuse recommended medical interventions and make what may seem like unreasonable or even harmful choices.
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Refusal of Psychiatric Treatment
• Debate regarding ability for patients who are involuntarily detained having the right to refuse Psychiatric interventions.
• Donaldson Case- US Supreme Court• ASK:– What is the goal of the detainment?– What is the goal of the Psychiatric intervention?– Will the patient continue the psychiatric medication
after discharge?
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Mental Health Advance Directives
• Sometimes called “Ulysses Contract”• Psychiatric patient prone to recurrence of illness• Patient’s autonomous decision about psychiatric
treatment during future grave episodes of psychiatric illness
• Advance Directive does not preclude involuntary treatment for danger to self/others
• Study: Only 1 of 71 patients offered decided to complete a Mental Health AD
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Confidentiality
• “Confidentiality embodies the recognition of a power never to be used.”2
• Interest of psychiatrist/therapist: achieving the goal of psychological therapy
• Teens (12-18) ought to have the ability to consent to psychiatric treatment without parental permission
• Limits of confidentiality ought to be clarified at the beginning of an encounter/relationship
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Duty to Warn
• Tarasoff Case• Must be specific threat to specific
person(s)• Violation of confidentiality justified for
safety• Warning to victim and police
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Patients with diminished capacity
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Bibliography
1. Appelbaum, P. Assessment of Patient’s Competence to Consent to Treatment. NEJM. 357; 18. 2007.
2. Block, S. and S. Green. Psychiatric Ethics, 4th Ed. Confidentiality (Joseph, D., et al.) p 177-209.
3. Block, S. and S. Green. Psychiatric Ethics, 4th Ed. Involuntary hospitalization and deinstitutionalization (Peele and Chodoff) p 212-228.
4. Lo, Bernard. Resolving Ethical Dilemmas., 5th Ed Ethical Issues in Psychiatry. Wolters Kluwer, Philadelphia, 2013. p 286-294.
5. Sessums, L. et al., Does this Patient Have Medical Decision-Making Capacity? JAMA 206; 4. 2011.
6. Soriano, M. and R. Lagman. When the Patient Says No. American Journal of Hospice & Palliative Medicine. 29(5) 401-404.
7. United States Conference of Catholic Bishops Ethical and Religious Directives for Catholic Health Care Services. 5th ed.