Ethics Case Workup: PsychiatryLaura Guidry-Grimes, Philosophy Ph.D. StudentSibley HospitalApril 5, 2012

What are the facts?Persons involved:

◦59 year old homeless woman◦Uncertain medical history

Diagnosis, prognosis:◦In hospital for fractured mandible

and injured fingerPatient preference/values:

◦“refuses surgery which she feels would be ‘disfiguring’”

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

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

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

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”

Capacity for medical decision-making: Different models & considerationsOutcome modelMinimal expression modelAlgorithm modelSliding scale model

Capacity for medical decision-making: Different models & considerations

Patient’s treatment

choice

Other’s risk/benefit

assessment of that choice in

comparison with other

alternatives

Level of decision-making

competence required

Grounds for believing

patient’s choice best

promotes/protects own well-

being

Consents to lumbar

puncture for presumed meningitis

Net balance substantially better than for

possible alternatives

Low/minimal Principally the benefit/risk assessment

made by others

Chooses lumpectomy

for breast cancer

Net balance roughly

comparable to that of other alternatives

Moderate Roughly same benefit/risk assessment

made by others ; best fits

patient’s conception of

own good

Refuses surgery for

simple appendecto

my

Net balance substantially worse than for

another alternative(s)

High/maximal Principally from patient’s

decision that the chosen

alternative best fits own

conception of own good

From Buchanan & Brock, pg. 53

Slid

ing s

cale

m

odel

Capacity for medical decision-making: Different models & considerationsNecessary components of

capacity◦Understanding◦Reasoning◦Appreciation◦Applying values

Capacity for medical decision-making: Different models & considerationsMental 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)

Capacity for medical decision-making: Different models & considerationsDC 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)

Capacity for medical decision-making: Different models & considerationsMental 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)

Capacity for medical decision-making: Different models & considerationsBipolar 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.)

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.

Preventive ethicsConcern about diagnosis

ambiguityIf 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

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 Disorders 80 (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.