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Newman MW, Keller CS. Medical Detention of Incapacitated Patients. J Gen Intern Med 2024:10.1007/s11606-024-09010-3. [PMID: 39186215 DOI: 10.1007/s11606-024-09010-3] [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] [Received: 05/20/2024] [Accepted: 08/13/2024] [Indexed: 08/27/2024]
Abstract
Inpatients with impaired decision-making capacity may attempt to leave the hospital prematurely. When no surrogate decision-maker is available, clinical teams often lack a legal basis to keep these patients. Provisions for emergency treatment and involuntary psychiatric holds are unsuitable and insufficient to address the problem. Clinicians need explicit legal authority to temporarily detain and treat incapacitated and unrepresented patients. Physician and hospital associations should lobby state legislatures to create new statutes for medical incapacity modeled after mental health laws.
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Affiliation(s)
- Mark W Newman
- University of Washington Department of Psychiatry and Behavioral Science, Seattle, WA, USA.
| | - Carolyn S Keller
- Division of General Internal Medicine, University of Washington Department of Medicine, Seattle, WA, USA
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2
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Waler N, Daubenspeck D. Ethical Considerations Surrounding Patient Refusal of Emergent Aortic Surgery. J Cardiothorac Vasc Anesth 2024; 38:542-548. [PMID: 37880039 DOI: 10.1053/j.jvca.2023.09.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 09/12/2023] [Indexed: 10/27/2023]
Affiliation(s)
- Nicholas Waler
- Department of Anesthesiology and Critical Care, University of Chicago, Chicago, IL.
| | - Danisa Daubenspeck
- Department of Anesthesiology and Critical Care, University of Chicago, Chicago, IL
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3
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Berkowitz E, Trevick S. Non-Psychiatric Treatment Refusal in Patients with Depression: How Should Surrogate Decision-Makers Represent the Patient's Authentic Wishes? HEC Forum 2024:10.1007/s10730-024-09522-9. [PMID: 38280180 DOI: 10.1007/s10730-024-09522-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2024] [Indexed: 01/29/2024]
Abstract
Patients with mental illness, and depression in particular, present clinicians and surrogate decision-makers with complex ethical dilemmas when they refuse life-sustaining non-psychiatric treatment. When treatment rejection is at variance with the beliefs and preferences that could be expected based on their premorbid or "authentic" self, their capacity to make these decisions may be called into question. If capacity cannot be demonstrated, medical decisions fall to surrogates who are usually advised to decide based on a substituted judgment standard or, when that is not possible, best interest. We propose that in cases where the patient meets the widely accepted cognitive criteria for capacity but is making decisions that appear inauthentic, the surrogate may best uphold patient autonomy by following a "restorative representation" model. We see restorative representation as a subset of substituted judgement in which the decision-maker retains responsibility for deciding as the patient would have, but discerns the decision their "truest self" would make, rather than inferring their current wishes, which are directly influenced by illness. Here we present a case in which the patient's treatment refusal and previously undiagnosed depression led to difficulty determining the patient's authentic wishes and placed a distressing burden on the surrogate decision-maker. We use this case to examine how clinicians and ethicists might better advise surrogates who find themselves making these clinically and emotionally challenging decisions.
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Affiliation(s)
- Esther Berkowitz
- Ascension Holy Family, 100 North River Rd, Des Plaines, IL, 60016, USA.
| | - Stephen Trevick
- Northwest Neurology, Ltd., 22285 North Pepper Rd #401, Barrington, IL, 60010, USA
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4
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Gaba A, Dorsett A, Martin SO, Chen B, Munjal S. Transcultural Psychiatry in Medical Ethics: Assessing Decision-Making Capacity within the Lens of an East African Refugee. THE JOURNAL OF CLINICAL ETHICS 2024; 35:190-198. [PMID: 39145576 DOI: 10.1086/730871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/16/2024]
Abstract
AbstractA 29-year-old female East African refugee with no formal psychiatric history and a medical history significant for HIV was admitted for failure to thrive and concern for bizarre behavior in the context of abandonment by her husband and separation from her child. After psychiatric evaluation, it was determined that she did not have the capacity to care for herself independently; adult protective services then pursued and was awarded guardianship. While admitted, the patient repeatedly refused medical treatment, had a feeding tube placed for forced nutrition and medications (though she did at one point remove this tube herself), and received two electroconvulsive therapy (ECT) treatments. Soon thereafter, the patient's court-appointed guardian met with the primary medical, psychiatric, and ethics teams to discuss goals of care in the setting of complex social and cultural needs. It was collectively determined that the patient's choices to refuse care (including nutrition, lab work, medications, and ECT) and some repeated behaviors (e.g., denial of divorce, denial of HIV, denial of need for care) could be considered culturally appropriate in the context of the acute stressors leading up to hospitalizations. All teams concluded, therefore, that the patient had the capacity to refuse these interventions and that further forced intervention would pose a greater chance of exacerbating her already-significant trauma history than improving her outcomes. Ultimately, the patient was able to be discharged into the care of her guardian, who would assist her in receiving support from members of her community who share her language and culture.
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5
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Caravella RA, Skimming K, Bradley MV. Psychiatric Consultation When a Patient Refuses Medical Care. Psychiatr Ann 2023. [DOI: 10.3928/00485713-20230103-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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6
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Navin MC, Brummett AL, Wasserman JA. Three Kinds of Decision-Making Capacity for Refusing Medical Interventions. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2022; 22:73-83. [PMID: 34344267 DOI: 10.1080/15265161.2021.1941423] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
According to a standard account of patient decision-making capacity (DMC), patients can provide ethically valid consent or refusal only if they are able to understand and appreciate their medical condition and can comparatively evaluate all offered treatment options. We argue instead that some patient refusals can be capacitated, and therefore ethically authoritative, without meeting the strict criteria of this standard account-what we call comparative DMC. We describe how patients may possess burdens-based DMC for refusal if they have an overriding objection to at least one burden associated with each treatment option or goals-based DMC for refusal if they have an overriding goal that is inconsistent with treatment. The overridingness of a patient's objections to burdens, or of their commitment to a goal, can justify the moral authority of their refusal, even when a patient lacks some of the cognitive capacities that standard accounts of DMC involve.
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Affiliation(s)
- Mark Christopher Navin
- Oakland University
- Beaumont Hospital - Royal Oak
- Oakland University William Beaumont School of Medicine
| | - Abram L Brummett
- Beaumont Hospital - Royal Oak
- Oakland University William Beaumont School of Medicine
| | - Jason Adam Wasserman
- Beaumont Hospital - Royal Oak
- Oakland University William Beaumont School of Medicine
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7
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Decision-Making Capacity to Refuse Treatment at the End of Life: The Need for Recognizing Real-World Practices. Clin Pract 2022; 12:760-765. [PMID: 36286065 PMCID: PMC9600193 DOI: 10.3390/clinpract12050079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 09/09/2022] [Accepted: 09/19/2022] [Indexed: 11/17/2022] Open
Abstract
End-of-life decision making is a troublesome ethical dilemma. These decisions should be made in trustful patient–doctor relationships. We aimed to propose a balanced approach when discussing this complex issue. We categorized the research into four approaches and suggest that a multidisciplinary approach may be appropriate. We also analyzed the pitfalls of the multidisciplinary approach. Our conclusion is two-fold. First, discussions in this field should be based on real-world practice. If this is not the case, the proposal may be armchair theory, which is not effective in a clinical setting. Second, interdisciplinary researchers should not stick to their position too firmly and should listen to others. Otherwise, proposals made will be paternalistic or philosophically biased. Therefore, when philosophical collaboration is applied to the topic of clinical bioethics, it is necessary to thoroughly examine different positions and carry out careful discussions with consideration for medical care settings. Researchers must also understand what is needed for a trustful patient–doctor relationship. By making such efforts, clinical bioethics will contribute to the wellbeing of patients.
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Angelos P. Classic Ethical Dilemma: When Is it Acceptable to Treat Patients over Their Objection? J Am Coll Surg 2021; 233:515-516. [PMID: 34563327 DOI: 10.1016/j.jamcollsurg.2021.07.683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 07/28/2021] [Indexed: 10/20/2022]
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9
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Ethical Framework to Guide Decisions of Treatment Over Objection. J Am Coll Surg 2021; 233:508-516.e1. [PMID: 34325018 DOI: 10.1016/j.jamcollsurg.2021.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 06/15/2021] [Accepted: 07/02/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Whether to proceed with a medical intervention over the objection of a patient who lacks capacity is a common problem facing practitioners. Despite this, there is a notable gap in the literature describing how to proceed in such situations in an ethically rigorous and consistent fashion. We elaborate on the practical application of the 2018 Rubin/Prager seven-question algorithm for ethics consultations regarding treatment over objection and we describe the impact of each of the seven questions. STUDY DESIGN We retrospectively review a series of consultations at Columbia University Irving Medical Center for treatment over objection in adult patients determined to lack capacity between April 2017 and May 2020. Outcomes regarding the final ethics recommendation and the assessment of each of the seven questions are reported. The statistical analysis was designed to determine which of the seven questions in the algorithm were most predictive of the final ethics recommendation. RESULTS In our series, there was an ethics recommendation to proceed over the objection of a patient in 63% of consultations. While all seven questions were considered to be important to the ethical analysis of a patient's situation, the presence of logistical barriers to treatment and the imminence of harm to a patient without treatment emerged as the most significant drivers of the recommendation of whether to proceed over objection or not. CONCLUSIONS Cases of treatment over objection in a patient lacking capacity are frequently encountered problems that requires a careful balance of patient autonomy and a physician's duty of beneficence. The application of the Rubin/Prager seven-question algorithm reliably guides a care team through such a complex ethical dilemma.
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O'Cionnaith C, Wand APF, Peisah C. Navigating the Minefield: Managing Refusal of Medical Care in Older Adults with Chronic Symptoms of Mental Illness. Clin Interv Aging 2021; 16:1315-1325. [PMID: 34285476 PMCID: PMC8285123 DOI: 10.2147/cia.s311773] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 06/21/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose The purpose of this case series is to illustrate the complexity of considerations across health (physical and mental), ethical, human rights and practical domains when an older adult with chronic symptoms of mental illness refuses treatment for a serious medical comorbidity. A broad understanding of these considerations may assist health care professionals in navigating this challenging but common aspect of clinical practice. Case Presentation Three detailed case reports are described. Participants were older adults with an acute presentation of a chronic mental illness, admitted to a specialized older persons mental health inpatient unit (OPMHU) in an Australian metropolitan hospital. Significant comorbid medical issues were detected or arose during the admission and the patient refused the recommended medical intervention. Data extracted from patients' medical records were analyzed and synthesized into detailed case reports using descriptive techniques. Each patient was assessed as lacking capacity for healthcare and treatment consent and did not have relatives or friends to assist with supported decision-making. Multifaceted aspects of decision-making and management are highlighted. Conclusion There are multiple complex issues to consider when an older adult with chronic symptoms of mental illness refuses treatment for serious comorbid medical conditions. In addition to optimizing management of the underlying mental illness (which may be impairing capacity to make healthcare decisions), clinicians should adopt a role of advocacy for their patients in considering the potential impact of ageism and stigma on management plans and inequities in physical healthcare. Consultation with specialist medical teams should incorporate multifaceted considerations such as potentially inappropriate treatment and optimum setting of care. Equally important is reflective practice; considering whether treatment decisions may infringe upon human rights or cause trauma.
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Affiliation(s)
- Cathal O'Cionnaith
- Older Persons Mental Health Service, Jara Unit, Concord Centre for Mental Health, Concord Repatriation General Hospital, Concord, NSW, Australia
| | - Anne P F Wand
- Older Persons Mental Health Service, Jara Unit, Concord Centre for Mental Health, Concord Repatriation General Hospital, Concord, NSW, Australia.,Specialty of Psychiatry, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.,Discipline of Psychiatry, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Carmelle Peisah
- Discipline of Psychiatry, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia.,Capacity Australia, Crows Nest, NSW, Australia
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Hamm B. Psychiatric Facilitation of Care When Requested for Assessment of Decision-Making Capacity. Psychiatr Ann 2021. [DOI: 10.3928/00485713-20210215-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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12
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Blum AW, Patron Romero VG, Shima C. Ethical Aspects of Enforced Medical Treatment in Patients with Psychiatric Illness. Psychiatr Ann 2021. [DOI: 10.3928/00485713-20210210-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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13
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Navin MC, Wasserman JA, Haimann MH. Treatment Over Objection-Moral Reasons for Reluctance. Mayo Clin Proc 2019; 94:1936-1938. [PMID: 31537308 DOI: 10.1016/j.mayocp.2019.08.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 07/15/2019] [Accepted: 08/16/2019] [Indexed: 10/26/2022]
Affiliation(s)
| | - Jason Adam Wasserman
- Department of Foundational Medical Studies, Oakland University William Beaumont School of Medicine, Rochester, MI
| | - Mark H Haimann
- Department of Foundational Medical Studies, Oakland University William Beaumont School of Medicine, Rochester, MI
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Beal ML, Oxman DA, Becker MA. Non-urgent Surgical Intervention Over Objection in a Patient Who Lacks Capacity: A Case Report. PSYCHOSOMATICS 2019; 61:277-280. [PMID: 31466812 DOI: 10.1016/j.psym.2019.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 07/16/2019] [Accepted: 07/17/2019] [Indexed: 11/15/2022]
Affiliation(s)
- Marissa L Beal
- Department of Psychiatry and Human Behavior, Thomas Jefferson University Hospital & Sidney Kimmel Medical College, Philadelphia, PA.
| | - David A Oxman
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine; and Jane & Leonard Korman Respiratory Institute, Thomas Jefferson University Hospital & Sidney Kimmel Medical College, Philadelphia, PA
| | - Madeleine A Becker
- Department of Psychiatry and Human Behavior, Thomas Jefferson University Hospital & Sidney Kimmel Medical College, Philadelphia, PA
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