Should a suicidal patient with Huntington's disease be hospitalized against her will? Attitudes among future physicians and lawyers and discussion of ethical issues

Suicidal Ideation Assessment in Individuals with Premanifest and Manifest Huntington Disease

BACKGROUND

Huntington disease (HD) is associated with increased risk of suicide.

OBJECTIVE

This study compares suicide ideation in HD to the general population, assesses factors associated with increased prevalence of suicidal thoughts, and compares clinician-rated to self-reported assessments of suicidal ideation.

METHODS

We examined 496 participants with premanifest or manifest HD. Clinician-rated suicidal ideation was measured using the Problem Behaviors Assessment - short form. Self-reported ideation was measured using two items from the HDQLIFE Concern with Death and Dying item bank. Independent sample t-tests were conducted to compare the prevalence of suicidal thoughts between our HD sample and the U.S.

POPULATION

Logistic regression analyses were used to determine characteristics associated with higher odds of clinically significant suicidal ideation. Kappa agreement coefficients were calculated to evaluate concurrence between clinician-rated and self-reported assessments.

RESULTS

Our sample had a significantly higher occurrence of suicidal ideation (19.76%) and suicidal plans (2.1%) than the general population (p < 0.0001). Odds of clinically significant suicidal ideation were 6.8 times higher in females (p = 0.04) on the clinician measure, and Hispanic/Latinos had 10.9 times higher odds than non-Hispanics (p = 0.025) on the self-report measure. Clinician-rated assessment had fair agreement (k = 0.2-0.4) with self-reported assessments, except in early stage HD where there was no overlap in the identification of participants with clinically significant suicidal ideation.

DISCUSSION

Assessment for suicidal ideation and clinically significant suicidal thoughts in HD with a multimodal approach that includes clinician-rated and self-report measures is critical at all stages of the disease.

Ethical challenges faced by healthcare professionals who care for suicidal patients: a scoping review

For each one of the approximately 800,000 people who die from suicide every year, an additional twenty people attempt suicide. Many of these attempts result in hospitalization or in contact with other healthcare services. However, many personal, educational, and institutional barriers make it difficult for healthcare professionals to care for suicidal individuals. We reviewed literature that discusses suicidal patients in healthcare settings in order to highlight common ethical issues and to identify knowledge gaps. A sample was generated via PubMed using keywords "[(ethics OR *ethic*) AND suicid*] AND [English (Language) OR French (Language)]" (final N = 52), ethics content was extracted according to scoping review methodology, and categorized thematically. We identified three main areas posing ethical challenges for health professionals caring for suicidal individuals and their families. These were: (1) making clinical decisions for patients in acute care or when presented with specific circumstances; (2) issues arising from therapeutic relationships in chronic care, and (3) organizational factors. There is considerable uncertainty about how to resolve ethical issues when caring for someone who is suicidal. The stigma associated with suicide and mental illness, problems associated with risk-benefit assessments, and the fear of being held liable for malpractice should a patient die by suicide were overarching themes present across these three categories. Caring for suicidal patients is clinically and ethically challenging. The current literature highlights the complexity and range of decisions that need to be made. More attention should be paid to the difficulties faced by healthcare professionals and the development of solutions.

French lay people's and health professionals' views regarding the acceptability of involuntary treatment of nursing home residents

OBJECTIVES

We examined the views of lay people and health professionals in France about involuntary treatment of residents in nursing homes.

METHOD

Participants (101 lay people, 20 nurses, 20 psychologists, and 10 physicians) were presented with a series of stories created by varying the levels of five factors: type of behavioral problem encountered (e.g., night-wandering), associated signs of dementia, physician's effort to explain the reason for treatment, resident's attitude (e.g., lasting reluctance), and physician's decision to prescribe psychotropic drugs or not. Participants were asked to judge the acceptability of the decision in each concrete case.

RESULTS

Three qualitatively different positions were found. The largest group (40% of the participants) viewed treatment of residents' behavioral problems as the most important objective. They felt it also important to respect residents' wishes and, therefore, to spend much time in talking with them about treatment. An almost equally large group (39%)--which included 60% of physicians--viewed respect for residents' autonomy as the most important consideration. A smaller group (21%)--including 40% of the psychologists--focused on the importance of taking time to talk with the residents. They also thought that treating patients against their will was unacceptable. Thus they took autonomy one step further than the preceding group.

CONCLUSION

It is important to reduce as much as possible the conflict between the principles of patient autonomy and perceived beneficence when caring for nursing home patients with behavior problems. This can be done by promoting their decision making abilities.

Accounts of suicidality in the Huntington disease community

Health professionals, researchers, and philosophers have debated extensively about suicide. Some believe suicides result from mental pathology, whereas others argue that individuals are capable of rational suicide. This debate is particularly poignant within illness communities, where individuals may be suffering from chronic and incurable conditions. This article engages with these issues by presenting the accounts of 20 individuals with Huntington disease (HD), a fatal degenerative condition, and 10 informal caregivers (e.g., spouses). Suicide is a leading cause of death amongst people with HD, with an incidence rate many times higher than the general population. In contrast to the majority of the academic literature on HD suicidality, study participants did not connect suicide with mental pathology. Instead, they perceived suicide as a response to the realities of living with HD, such as prolonged physiological degeneration and the need for long-term intensive health care. These findings are subsequently discussed in relation to the rational-pathological suicide binary.

French lay people's views regarding the acceptability of involuntary hospitalization of patients suffering from psychiatric illness

PURPOSE

To understand how lay people and health professionals in France judge the acceptability of hospitalizing a psychiatric patient against his will.

METHODS

123 lay people, 20 nurses, 5 psychologists, and 6 physicians judged the acceptability of involuntary hospitalization in each of 36 scenarios consisting of all combination of 4 factors: patient's adherence to treatment (agrees to take his medications or not); risk of suicide (none, immediate, multiple past attempts); risk of harming others (none, immediate, history of violence against others); attitude of patient's family (favorable to involuntary hospitalization or not). The judgment data were subjected to cluster analysis and subsequently to analysis of variance.

RESULTS

4 clusters were identified and labeled according to the factors that affected judgments: Never Favorable (7 participants, with mean acceptability judgment of 1.30 on a scale of 0-10); Threat to Others (35, with mean judgment of 8.68 when risk high, 2.94 when risk low), Threat to Others or Self and Adherence (88, with mean judgment of 6.89), and Always Favorable (24, with mean judgment of 8.41).

CONCLUSIONS

95% of participants agreed that involuntary hospitalization is acceptable under certain conditions, especially - in accordance with French law - when the patient presents a risk to others.

Attitudes among medical and law students toward decision-making in regard to involuntary psychiatric hospitalization

BACKGROUND

The management of individuals with mental illnesses sometimes requires involuntary hospitalization. The Israel Mental Health Act requires that cases of involuntary psychiatric hospitalization (IPH) be periodically reviewed by the district psychiatric committee. The discussion in the committee often leads to debate regarding the need for an IPH potentially depriving the patient of his freedom. Little is known about the way in which the psychiatrists and attorneys on these committees arrive at their decisions. The present study was designed to examine the views of future doctors and attorneys concerning cases of possible IPH to determine whether their decisions would be influenced by their respective professional educational backgrounds.

METHODS

After compiling demographic data, we asked 170 students from each of the two disciplines what their decision would be in two hypothetical cases that dealt with the question of a prolongation of a psychiatric hospitalization. Questionnaires examining social distance and possible stigmatizing views concerning psychiatric patients were also distributed and collected.

RESULTS

The response rates for the medical and law students were, respectively, 90% and 85%. We found no differences between the medical and law students regarding their views on prolongation of a psychiatric hospitalization. This was consistent regardless of whether the hospitalization was against the patient's will or according to his wish and against the treating physicians' advice. We also found that the medical and law students had similar general views regarding psychiatric patients, but that the latter evidenced greater social distance than the former.

CONCLUSIONS

Academic background and socialization were not found to influence the decisions of students regarding IPH. Educational programs and exposure to psychiatric patients during law studies are proposed to lessen psychiatric stigma and promote better understanding between members of the two disciplines.

Distinguishing among irrational suicide and other forms of hastened death: implications for clinical practice

BACKGROUND

The increasing recognition that not all hastened death is irrational challenges clinical practice.

OBJECTIVE

The author distinguishes among the various forms of hastened death. Psychiatrists may be consulted when patients ask to hasten their death in any of the ways described, contrasted, and illustrated in this article.

CONCLUSION

The rational desire to hasten death may call for unconventional psychiatric responses. The author discusses the error of failing to provide life-saving medical treatment over the objection of someone who has attempted suicide and the error of trying to prevent rational persons suffering from incurable illness from hastening their death.

Should children and adolescents be tested for Huntington's disease? Attitudes of future lawyers and physicians in Switzerland

The objective of the study was to identify future lawyers' and physicians' views on testing children for Huntington's disease (HD) against parents' wishes. After receiving general information about HD, patient autonomy and confidentiality, law students and advanced medical students were shown an interview with a mother suffering from HD who is opposed to informing and testing her two children (aged 10 and 16) for HD. Students then filled out questionnaires concerning their agreement with testing. No significant differences were found between medical and law students or between students from different courses concerning the adolescent son. Three quarters of students thought that he should be told about his mother's disease, and 91% thought the adolescent son should have the opportunity of genetic testing for HD himself. However, significant differences were found concerning the 10-year old son, with 44% of law students and 30% of medical students in favour of testing the child for HD. Students raised some important ethical issues in their elective comments. In conclusion, we found highly positive attitudes towards informing a 16-year old of his mother's HD and offering to test him. These attitudes were not in tune with guidelines. Students did not consider several practical and ethical issues of genetic testing of children and adolescents. Specific education should ensure that attitudes are based on sufficiently detailed knowledge about all aspects of genetic testing of children to discourage pressures on persons at risk of HD.