2
|
Ethical challenges faced by healthcare professionals who care for suicidal patients: a scoping review. Monash Bioeth Rev 2019; 35:50-79. [PMID: 29667145 DOI: 10.1007/s40592-018-0076-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
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.
Collapse
|
3
|
Quinlivan L, Nowland R, Steeg S, Cooper J, Meehan D, Godfrey J, Robertson D, Longson D, Potokar J, Davies R, Allen N, Huxtable R, Mackway-Jones K, Hawton K, Gunnell D, Kapur N. Advance decisions to refuse treatment and suicidal behaviour in emergency care: 'it's very much a step into the unknown'. BJPsych Open 2019; 5:e50. [PMID: 31530303 PMCID: PMC6582215 DOI: 10.1192/bjo.2019.42] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Complex challenges may arise when patients present to emergency services with an advance decision to refuse life-saving treatment following suicidal behaviour. AIMS To investigate the use of advance decisions to refuse treatment in the context of suicidal behaviour from the perspective of clinicians and people with lived experience of self-harm and/or psychiatric services. METHOD Forty-one participants aged 18 or over from hospital services (emergency departments, liaison psychiatry and ambulance services) and groups of individuals with experience of psychiatric services and/or self-harm were recruited to six focus groups in a multisite study in England. Data were collected in 2016 using a structured topic guide and included a fictional vignette. They were analysed using thematic framework analysis. RESULTS Advance decisions to refuse treatment for suicidal behaviour were contentious across groups. Three main themes emerged from the data: (a) they may enhance patient autonomy and aid clarity in acute emergencies, but also create legal and ethical uncertainty over treatment following self-harm; (b) they are anxiety provoking for clinicians; and (c) in practice, there are challenges in validation (for example, validating the patient's mental capacity at the time of writing), time constraints and significant legal/ethical complexities. CONCLUSIONS The potential for patients to refuse life-saving treatment following suicidal behaviour in a legal document was challenging and anxiety provoking for participants. Clinicians should act with caution given the potential for recovery and fluctuations in suicidal ideation. Currently, advance decisions to refuse treatment have questionable use in the context of suicidal behaviour given the challenges in validation. Discussion and further patient research are needed in this area. DECLARATION OF INTEREST D.G., K.H. and N.K. are members of the Department of Health's (England) National Suicide Prevention Advisory Group. N.K. chaired the National Institute for Health and Care Excellence (NICE) guideline development group for the longer-term management of self-harm and the NICE Topic Expert Group (which developed the quality standards for self-harm services). He is currently chair of the updated NICE guideline for Depression. K.H. and D.G. are NIHR Senior Investigators. K.H. is also supported by the Oxford Health NHS Foundation Trust and N.K. by the Greater Manchester Mental Health NHS Foundation Trust.
Collapse
Affiliation(s)
- Leah Quinlivan
- Research Associate, Centre for Suicide Prevention, Manchester Academic Health Science Centre, University of Manchester; and NIHR Greater Manchester Patient Safety Translational Research Centre, UK
| | - Rebecca Nowland
- Research Associate, Centre for Suicide Prevention, Manchester Academic Health Science Centre, University of Manchester, UK
| | - Sarah Steeg
- Research Associate, Centre for Suicide Prevention, Manchester Academic Health Science Centre, University of Manchester, UK
| | - Jayne Cooper
- Senior Research Fellow, Centre for Suicide Prevention, Manchester Academic Health Science Centre, University of Manchester, UK
| | - Declan Meehan
- Senior Mental Health Practitioner and Operational Manager, Greater Manchester Mental Health NHS Foundation Trust, UK
| | - Joseph Godfrey
- Emergency Medicine Consultant, Emergency Department, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, UK
| | | | - Damien Longson
- Consultant Psychiatrist, Greater Manchester Mental Health NHS Foundation Trust, UK
| | - John Potokar
- Consultant Psychiatrist, Avon and Wiltshire Mental Health Partnership NHS Trust; University Hospitals Bristol NHS Foundation Trust; and Department of Population Health Sciences, University of Bristol, UK
| | - Rosie Davies
- Research Fellow, The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West (NIHR CLAHRC West) at University Hospitals Bristol NHS Foundation Trust; and Faculty of Health and Applied Sciences, University of the West of England, UK
| | - Neil Allen
- Barrister and Senior Lecturer, School of Law, University of Manchester, UK
| | - Richard Huxtable
- Professor of Medical Ethics and Law, Department of Population Health Sciences, University of Bristol, UK
| | - Kevin Mackway-Jones
- Emergency Medicine Consultant, Emergency Department, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, UK
| | - Keith Hawton
- Professor of Psychiatry, Centre for Suicide Research, University Department of Psychiatry, Warneford Hospital, UK
| | - David Gunnell
- Professor of Epidemiology, Department of Population Health Sciences, University of Bristol; and National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, UK
| | - Nav Kapur
- Professor of Psychiatry and Population Health and Honorary Consultant Psychiatrist, Centre for Suicide Prevention, Manchester Academic Health Science Centre, University of Manchester; NIHR Greater Manchester Patient Safety Translational Research Centre; and Greater Manchester Mental Health NHS Foundation Trust, UK
| |
Collapse
|
4
|
Harari DY, Macauley RC. Determining code status on inpatient psychiatry. Gen Hosp Psychiatry 2018; 51:1-4. [PMID: 29156396 DOI: 10.1016/j.genhosppsych.2017.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 10/17/2017] [Accepted: 10/25/2017] [Indexed: 11/25/2022]
Affiliation(s)
- David Y Harari
- The University of Vermont Medical Center, 111 Colchester Ave, Burlington, VT 05401, United States.
| | | |
Collapse
|
5
|
Assessing Decision Making Capacity for Do Not Resuscitate Requests in Depressed Patients: How to Apply the "Communication" and "Appreciation" Criteria. HEC Forum 2017; 29:303-311. [PMID: 28534181 DOI: 10.1007/s10730-017-9323-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The Patient Self Determination Act (PSDA) of 1991 brought much needed attention to the importance of advance care planning and surrogate decision-making. The purpose of this law is to ensure that a patient's preferences for medical care are recognized and promoted, even if the patient loses decision-making capacity (DMC). In general, patients are presumed to have DMC. A patient's DMC may come under question when distortions in thinking and understanding due to illness, delirium, depression or other psychiatric symptoms are identified or suspected. Physicians and other healthcare professionals working in hospital settings where medical illness is frequently comorbid with depression, adjustment disorders, demoralization and suicidal ideation, can expect to encounter ethical tension when medically sick patients who are also depressed or suicidal request do not resuscitate orders.
Collapse
|