1
|
Madrigal VN, Feltman DM, Leuthner SR, Kirsch R, Hamilton R, Dokken D, Needle J, Boss R, Lelkes E, Carter B, Macias E, Bhombal S. Bioethics for Neonatal Cardiac Care. Pediatrics 2022; 150:189885. [PMID: 36317974 DOI: 10.1542/peds.2022-056415n] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND Clinicians caring for neonates with congenital heart disease encounter challenges with ethical implications in daily practice and must have some basic fluency in ethical principles and practical applications. METHODS Good ethical practice begins with a thorough understanding of the details and narrative of each individual case, examination via classic principles of bioethics, and further framing of that translation into practice. RESULTS We explore some of these issues and expand awareness through the lens of a case presentation beginning with fetal considerations through end-of-life discussions. CONCLUSIONS We include specific sections that bring attention to shared decision-making, research ethics, and outcomes reporting. We review empirical evidence and highlight recommendations.
Collapse
Affiliation(s)
- Vanessa N Madrigal
- Department of Pediatrics, Division of Critical Care Medicine and Pediatric Ethics Program, Children's National Hospital, George Washington University, Washington, District of Columbia
| | - Dalia M Feltman
- NorthShore University HealthSystem Evanston Hospital, University of Chicago, Pritzker School of Medicine, Chicago, Illinois
| | - Steven R Leuthner
- Departments of Pediatrics and Bioethics, Division of Neonatology, Children's Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Roxanne Kirsch
- Department of Critical Care, Division Cardiac Critical Care Medicine; Department of Bioethics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Rekha Hamilton
- Mednax Inc. Cook Children's Medical Center, Fort Worth, Texas
| | - Deborah Dokken
- Family Leader and Staff Member, Institute for Patient and Family-Centered Care, Bethesda, Maryland
| | - Jennifer Needle
- Department of Pediatrics and the Center for Bioethics, University of Minnesota, Minneapolis, Minnesota
| | - Renee Boss
- Department of Pediatrics, Johns Hopkins School of Medicine and Berman Institute of Bioethics, Baltimore, Maryland
| | - Efrat Lelkes
- Department of Pediatrics, Divisions of Critical Care Medicine and Palliative Medicine, Bioethics, University of California San Francisco, San Francisco, California
| | - Brian Carter
- Departments of Humanities and Pediatrics, Division of Neonatology and Bioethics Center, Children's Mercy Hospital, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Eduardo Macias
- Department of Pediatrics, Division of Pediatric Cardiology. University Hospital, University of Texas, San Antonio, Texas
| | - Shazia Bhombal
- Department of Pediatrics, Lucile Packard Children's Hospital. Stanford, Palo Alto, California
| |
Collapse
|
2
|
Andreoli A, Burnand Y, Cochennec MF, Ohlendorf P, Frambati L, Gaudry-Maire D, Di Clemente T, Hourton G, Lorillard S, Canuto A, Frances A. Disappointed Love and Suicide: A Randomized Controlled Trial of "Abandonment Psychotherapy" Among Borderline Patients. J Pers Disord 2016; 30:271-87. [PMID: 26111250 DOI: 10.1521/pedi_2015_29_196] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
To determine whether ambulatory psychotherapy targeted to abandonment experiences and fears can reduce suicidality and improve outcome in borderline patients referred to the emergency room with major depressive disorder and self-destructive behavior severe enough to require medical/surgical treatment and a brief psychiatric hospitalization. A total of 170 subjects were randomized at hospital discharge into three treatment groups: treatment as usual (TAU), abandonment psychotherapy delivered by certified psychotherapists, and abandonment psychotherapy delivered by nurses. Assessments were performed before randomization and at 3-month follow-up. Continued suicidality and other outcome measures were significantly worse in the treatment-as-usual as compared to both abandonment psychotherapy groups, but there were no differences between the two psychotherapy groups. These results suggest the efficacy of manualized psychotherapy that specifically targets the abandonment fears and experiences that are so common as precipitants to suicidal and self-destructive acts in borderline patients. It does not appear that formal psychotherapy training is associated with better outcomes.
Collapse
Affiliation(s)
- A Andreoli
- Psychiatry Department, University of Geneva, Service de liaison psychiatrique et d'intervention de crise, Geneva University Hospital, Geneva, Switzerland
| | - Y Burnand
- Psychiatry Department, University of Geneva, Service de liaison psychiatrique et d'intervention de crise, Geneva University Hospital, Geneva, Switzerland
| | - M-F Cochennec
- Psychiatry Department, University of Geneva, Service de liaison psychiatrique et d'intervention de crise, Geneva University Hospital, Geneva, Switzerland
| | - P Ohlendorf
- Psychiatry Department, University of Geneva, Service de liaison psychiatrique et d'intervention de crise, Geneva University Hospital, Geneva, Switzerland
| | - L Frambati
- Psychiatry Department, University of Geneva, Service de liaison psychiatrique et d'intervention de crise, Geneva University Hospital, Geneva, Switzerland
| | - D Gaudry-Maire
- Psychiatry Department, University of Geneva, Service de liaison psychiatrique et d'intervention de crise, Geneva University Hospital, Geneva, Switzerland
| | - Th Di Clemente
- Psychiatry Department, University of Geneva, Service de liaison psychiatrique et d'intervention de crise, Geneva University Hospital, Geneva, Switzerland
| | - G Hourton
- Psychiatry Department, University of Geneva, Service de liaison psychiatrique et d'intervention de crise, Geneva University Hospital, Geneva, Switzerland
| | - S Lorillard
- Psychiatry Department, University of Geneva, Service de liaison psychiatrique et d'intervention de crise, Geneva University Hospital, Geneva, Switzerland
| | - A Canuto
- Psychiatry Department, University of Geneva, Service de liaison psychiatrique et d'intervention de crise, Geneva University Hospital, Geneva, Switzerland
| | - A Frances
- Duke University, Durham, North Carolina (Emeritus)
| |
Collapse
|
3
|
Abstract
Psychotherapy is an effective and often highly cost-effective medical intervention for many serious psychiatric conditions. Psychotherapy can also lead to savings in other medical and societal costs. It is at times the firstline and most important treatment and at other times augments the efficacy of psychotropic medication. Many patients are in need of more prolonged and intensive psychotherapy, including those with personality disorders and those with chronic complex psychiatric conditions often with severe anxiety and depression. Many patients with serious and complex psychiatric illness have experienced severe early life trauma in an atmosphere in which family members or caretakers themselves have serious psychiatric disorders. Children and adolescents with learning disabilities and those with severe psychiatric disorders can also require more than brief treatment. Other diagnostic groups for whom psychotherapy is effective and cost-effective include patients with schizophrenia, anxiety disorders (including posttraumatic stress disorder), depression, and substance abuse. In addition, psychotherapy for the medically ill with concomitant psychiatric illness often lowers medical costs, improves recovery from medical illness, and at times even prolongs life compared to similar patients not given psychotherapy. While "cost-effective" treatments can yield savings in healthcare costs, disability claims, and other societal costs, "cost-effective" by no means translates to "cheap" but instead describes treatments that are clinically effective and provided at a cost that is considered reasonable given the benefit they provide, even if the treatments increase direct expenses. In the current insurance climate in which Mental Health Parity is the law, insurers nonetheless often use their own non-research and non-clinically based medical necessity guidelines to subvert it and limit access to appropriate psychotherapeutic treatments. Many patients, especially those who need extended and intensive psychotherapy, are at risk of receiving substandard care due to inadequate insurance reimbursement. These patients remain vulnerable to residual illness and the concomitant sequelae in lost productivity, dysfunctional interpersonal and family relationships, comorbidity including increased medical and surgical services, and increased mortality.
Collapse
Affiliation(s)
- Susan G Lazar
- Clinical Professor of Psychiatry: Georgetown University School of Medicine, George Washington University School of Medicine, Uniformed Services University of the Health Sciences; Supervising and Training Analyst, Washington Psychoanalytic Institute
| |
Collapse
|
4
|
Barnow S, Linden M, Schaub RT. The impact of psychosocial and clinical variables on duration of inpatient treatment for depression. Soc Psychiatry Psychiatr Epidemiol 1997; 32:312-6. [PMID: 9299923 DOI: 10.1007/bf00805434] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The duration of psychiatric hospital stays becomes increasingly important as economic pressures on medicine mount. Psychiatric hospitals, in particular, search for ways to cut costs without sacrificing efficiency. There is no doubt that clinical depression is one of the most important cost factors in psychiatry. Former studies have concentrated mainly on the influence of clinical variables such as the severity or subtype of depression on the length of stay (LOS). However, it can also be assumed that life situations or psychosocial variables in general might influence LOS. Data from 736 admissions between January 1983 and 1991 with a diagnosis of depression were examined to test the hypothesis that psychosocial and clinical variables influence LOS. Results showed a significant influence of age, marital status and gender, as well as severity and type of depression, on duration of inpatient treatment. Age, female gender, being widowed or divorced, the diagnosis of "endogenous depression" and severity were all associated with longer LOS. There was an interaction of gender, marital status and perceived loneliness, as well as an interaction of severity of depression with gender, both of which were associated with LOS.
Collapse
Affiliation(s)
- S Barnow
- Department of Psychiatry, Free University of Berlin, Germany
| | | | | |
Collapse
|