Ethics Grand Rounds: Dilemmas in Psychiatric Care

Presented by Andrea Chatburn, DO, MAMedical Director for Ethics

9.29.2015

www.providence.org/ethics

Objectives

Review and Discuss:• Moral Distress in Caregiving• Refusal of medical interventions• Involuntary psychiatric treatment• Psychiatric Advance Directives & Ulysses

Contracts• Confidentiality• Limits of confidentiality

Conflicting Values Moral Distress

• Government, representing society’s interests

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.

However:

• Severe symptomatic Psychiatric illness may impair the patient’s expression of autonomy• Psychiatric treatment may restore

autonomy • Goal: harm reduction

Capacity- Medical

Capacity is both specific and dynamic. Specific Question Specific Time Dynamic- can change based on time and

question

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

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

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)

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?

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

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.

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.

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.

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?

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

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

Duty to Warn

• Tarasoff Case• Must be specific threat to specific

person(s)• Violation of confidentiality justified for

safety• Warning to victim and police

Patients with diminished capacity

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.