Ethics Case Workup: Psychiatry

1. Ethics Case Workup: Psychiatry Laura Guidry-Grimes, Philosophy Ph.D. Student Sibley Hospital April 5, 2012

2. What are the facts? • Persons involved: • 59 year old homeless woman • Uncertain medical history • Diagnosis, prognosis: • In hospital for fractured mandible and injured finger • Patient preference/values: • “refuses surgery which she feels would be ‘disfiguring’”

3. What are the facts? • Chronology • 12/19: Patient arrives at GUH with open wounds and open/fractured mandible from alleged assault • Refuses treatment, analgesics • Staff contact parishioner and pastor, who report that patient has untreated bipolar disorder, increased erratic behavior, and stalking history

4. What are the facts? • Chronology • Parishioner talks to patient and reassures her that surgery is best option, so she consents. • 12/21: Surgery successfully performed • 12/24: Patient leaves against medical advice during post-op

5. What is the issue? • Patient refuses surgery to repair fractured mandible • Without surgery, patient will experience a)pain, b) loss of some functions, and c) risk of infection that could become life-threatening

6. Framing of the issue: Who should make the decision? • “Patient is oriented to self, ‘hospital’ and ‘December 2011’, not sure of day/date  but says she lives on the street and has ‘no need to know that’. • After detailed discussion of risks/benefits of surgery vs no surgery, pt clearly able to state understanding of risks—including risks of malunion, decreased function or range of function. […] infection which could be severe—even leading to death.” • Psychiatry team evaluated her and concluded “she was able to consent for herself”

7. Capacity for medical decision-making: Different models & considerations • Outcome model • Minimal expression model • Algorithm model • Sliding scale model

8. Capacity for medical decision-making: Different models & considerations Sliding scale model From Buchanan & Brock, pg. 53

9. Capacity for medical decision-making: Different models & considerations • Necessary components of capacity • Understanding • Reasoning • Appreciation • Applying values

10. Capacity for medical decision-making: Different models & considerations • Mental illness • Involuntary hospitalization determination separate from involuntary treatment determination (Buchanan & Brock 311) • Grounds for involuntary commitment • Imminent danger to self or others • Likely to “suffer substantial mental or physical deterioration” (1982 APA Guidelines)

11. Capacity for medical decision-making: Different models & considerations • DC Hospitalization of the Mentally Ill Act & Mental Health Commitment Emergency Act of 2002 • Administrator of hospital “shall, admit and detain for purposes of emergency observation and diagnosis a person” if he/she • “Has examined the person; • Is of the opinion that the person has symptoms of a mental illness and, because of the mental illness, is likely to injure himself or others unless the person is immediately hospitalized; and • Is of the opinion that hospitalization is the least restrictive form of treatment available to prevent the person from injuring himself or others” (DC B14-501)

12. Capacity for medical decision-making: Different models & considerations • Mental illness • Compromised capacity? • Understanding – delusional beliefs? • Reasoning – inability to form justification? • Appreciation – inability to grasp consequences? • Ability to apply values – distorted or unstable values? • Illnesses, symptoms, and individuals vary • No blanket statements about competence/capacity are warranted • Studies show that even patients with schizophrenia are less compromised when educational efforts are made (Misra & Ganzini 118)

13. Capacity for medical decision-making: Different models & considerations • Bipolar Disorder • “may alter insight into one’s current situation and the ability to foresee one’s future” (Misra & Ganzini 120) • “they will have trouble applying the risks and benefits of the protocol information to their own particular situation by overestimating a good outcome or denying risks” (ibid.)

14. Conclusion & Recommendation • Correctly deemed competent • Appears to have sufficient understanding, appreciation, and ability to apply her values • Internal rationality/reasoning not documented • Danger: risk of infection, threat not imminent • If parishioner had not persuaded the patient, her refusal should have been respected.

15. Preventive ethics • Concern about diagnosis ambiguity • If the hospital had used innovative educational techniques or approached empathic engagement differently, would they have needed to contact the parishioner to communicate to her the risks/benefits of the surgery? • Medical chart consistency

16. References • 21 District of Columbia Code Sec. 5. 2001. Web. • Buchanan, Allen E. & Dan W. Brock. Deciding for Others: The Ethics of Surrogate Decision Making. Cambridge: Cambridge University Press, 1990. • Charland, Louis C. “Mental Competence and Value: The Problem of Normativity in the Assessment of Decision-Making Capacity”. Psychiatry, Psychology, and Law 8.2 (2001): 135-145. • District of Columbia Council. Mental Health Commitment Emergency Act of 2002. B14-0501. 30 January 2002. Web. • Drane, James F. “The Many Faces of Competency”. In Ethics of Psychiatry: Insanity, Rational Autonomy, and Mental Health Care, Ed. Rem B. Edwards. Amherst: Prometheus Books, 1997. 206-217. • Jones, Roger C. & Timothy Holden. “A Guide to Assessing Decision-Making Capacity”. Cleveland Clinic Journal of Medicine 71.12 (Dec 2004): 971-975. • Misra, Sahana & Linda Ganzini. “Capacity to Consent to Research among Patients with Bipolar Disorder”. Journal of Affective Disorders80 (2004): 115-123. • Sturman, Edward D. “The Capacity to Consent to Treatment and Research: A Review of Standardized Assessment Tools”. Clinical Psychology Review 25 (2005): 954-974.