Compulsory Treatment in Chronic Anorexia Nervosa by All Means? Searching for a Middle Ground Between a Curative and a Palliative Approach

Persons with mental disorders and assisted dying practices in Spain: An overview

On 25 June 2021, the Law on Euthanasia in Spain came into force, providing for two modes of helping an individual end their life: euthanasia and/or medically assisted suicide. Among the requisites that a request for euthanasia has to fulfil are that the individual must be suffering a severe, chronic and debilitating condition or a severe and incurable disease, at the same time as that person shows the necessary competence to decide. The possibility exists that a patient suffering mental health problems submits such a request; however, the specific characteristics of a mental health disorder make such a request considerably more complex. In this article, based on a narrative review of the law itself and the related literature, the requisites established under the law are analysed from an ethical-legal perspective with the aim of defining when a request for euthanasia from a person with a mental health disorder may be deemed legitimate and in line with legal provisions. This should help clinicians make rational, reasoned decisions when dealing with a request of this type.

Palliative psychiatry in a narrow and in a broad sense: A concept clarification

Even with optimal treatment, some persons with severe and persistent mental illness do not achieve a level of mental health, psychosocial functioning and quality of life that is acceptable to them. With each unsuccessful treatment attempt, the probability of achieving symptom reduction declines while the probability of somatic and psychological side effects increases. This worsening benefit-harm ratio of treatment aiming at symptom reduction has motivated calls for implementing palliative approaches to care into psychiatry (palliative psychiatry). Palliative psychiatry accepts that some cases of severe and persistent mental illness can be irremediable and calls for a careful evaluation of goals of care in these cases. It aims at reducing harm, relieving suffering and thus improving quality of life directly, working around irremediable psychiatric symptoms. In a narrow sense, this refers to patients likely to die of their severe and persistent mental illness soon, but palliative psychiatry in a broad sense is not limited to end-of-life care. It can - and often should - be integrated with curative and rehabilitative approaches, as is the gold standard in somatic medicine. Palliative psychiatry constitutes a valuable addition to established non-curative approaches such as rehabilitative psychiatry (which focuses on psychosocial functioning instead of quality of life) and personal recovery (a journey that persons living with severe and persistent mental illness may undertake, not necessarily accompanied by mental health care professionals). Although the implementation of palliative psychiatry is met with several challenges such as difficulties regarding decision-making capacity and prognostication in severe and persistent mental illness, it is a promising new approach in caring for persons with severe and persistent mental illness, regardless of whether they are at the end of life.

Severe and Enduring Anorexia Nervosa and Futility: A Time for Every Purpose?

The concept of futility in the treatment of individuals with severe and enduring anorexia nervosa remains controversial and has significant legal and ethical considerations. For those who have been unremittingly ill for 8 to 12 years, full recovery, although possible, is unlikely, and alternatives to traditional, active treatment must be explored. The harm reduction model, palliative care, and end-of-life care are explored as meaningful and reasonable treatments for this population. Landmark cases demonstrating the legal and ethical controversy of such treatment are explored.

The harms of punishing substance use during pregnancy

As rates of substance use have increased in the United States, rates of substance-involved pregnancies have also been on the rise, inspiring new civil policies designed to punish pregnant and parenting individuals who engage in substance use or are living with an untreated substance use disorder. Proponents of punitive civil policies argue that such policies will deter substance use behaviors and/or that substance use during pregnancy deserves punishment for harming the fetus. Current scientific evidence invalidates both claims, offering compelling evidence that punitive civil policies often worsen the harms of substance use for both parent and child. In this commentary, we review this evidence and explain how punitive policies that threaten child removal and the termination of parental rights exacerbate the very problems they are ostensibly designed to reduce. Rather than coercive and punitive responses, families affected by substance use need greater access to affordable, evidence-based treatment as well as services that address the structural and relational concerns underlying substance use. Above all, responses to perinatal substance use in both policy and practice should prioritize keeping families together.

Evaluating Ineffective Treatments: A Proposed Model for Discussing Futility in Psychiatric Illness

BACKGROUND

Treatment futility and terminality discussions arise rarely in psychiatric practice, frequently instilling apprehension, as there is little written that defines these terms in relation to mental illness. It therefore remains uncertain how to deal with cases that are refractory to multimodal interventions and that demonstrate limited improvement or even a worsening trajectory. Any viable solution needs to respect patient autonomy and maintain both beneficence and nonmaleficence, while taking into account the strained resources of the mental health care system as a whole.

OBJECTIVE

This article reviews historical conflicts surrounding the notion of futility in psychiatric disorders, and proposes and elaborates a set of six criteria that psychiatrists can use in working through these difficult cases. Given the potential controversy involving futility in psychiatry, it proves helpful to understand its similarity to the notion of futility in standard medical contexts. This article also works through some of the common concerns or objections regarding the application of futility in psychiatric contexts.

CONCLUSIONS

Futility in psychiatric illness is a concept that the psychiatric community needs to understand and address, given the limited treatment options available to our field, as well as the limitations of health care resources. The proposed framework allows for ethically appropriate treatment decisions for treatment-resistant patients-respecting their individual wishes while ensuring appropriate care.

Compulsory Interventions in Severe and Persistent Mental Illness: A Survey on Attitudes Among Psychiatrists in Switzerland

Background: Some psychiatric patients develop severe and persistent mental illness (SPMI), which, for a variety of reasons, can be therapy-refractory. Sometimes, treatment is not considered helpful by the patients themselves and does not improve their subjective quality of life. Furthermore, many SPMI patients experience compulsory interventions such as seclusion, restraint, or treatment against their will, which can cause harm. Methods: In a cross-sectional survey of 1,311 German-speaking psychiatrists in Switzerland, participants were asked about the care of SPMI patients in general, and about their attitudes with regard to compulsory interventions in particular, using three case vignettes of patients with severe and persistent anorexia nervosa, schizophrenia and depression. Results: Out of 1,311 contacted psychiatrists, 457 (34.9%) returned the completed survey. In general, 91.0% found it important or very important to respect SPMI patients' autonomy in decision making. However, based on three different clinical case vignettes, 36.8% of psychiatrists would act against the wishes of the patient with severe and persistent schizophrenia, 34.1% against the wishes of the patient with severe and persistent depression, and 21.1% against the wishes of the patient with severe and persistent anorexia nervosa, although all patients were stated to have preserved decision-making capacity. With regard to the case vignettes, 41.1% considered compulsory interventions leading to a temporary reduction of quality of life acceptable in the patient with severe and persistent schizophrenia, 39.4% in the patient with severe and persistent depression, and 25.6% in the patient with severe and persistent anorexia nervosa, although it was stated in all three case vignettes that two independent experts ascribed the patients decision-making capacity regarding their illness and further treatment. Conclusions: Many psychiatrists in our sample found themselves in an ethical dilemma between autonomy and the provision of medical care. While most respondents respect the autonomy of SPMI patients, many saw the need to perform compulsory interventions even though it was clearly and prominently stated that two independent psychiatrists had ascribed the patients in the case vignettes decision-making capacity. Further examination of these conflicting views is warranted, perhaps along with the development of guidelines for such situations.

Coercive Measures in Psychiatry: A Review of Ethical Arguments

Introduction: Coercion is frequent in clinical practice, particularly in psychiatry. Since it overrides some fundamental rights of patients (notably their liberty of movement and decision-making), adequate use of coercion requires legal and ethical justifications. In this article, we map out the ethical elements used in the literature to justify or reject the use of coercive measures limiting freedom of movement (seclusion, restraint, involuntary hospitalization) and highlight some important issues. Methods: We conducted a narrative review of the literature by searching the PubMed, Embase, PsycINFO, Google Scholar and Cairn.info databases with the keywords "coercive/compulsory measures/care/treatment, coercion, seclusion, restraint, mental health, psychiatry, involuntary/compulsory hospitalization/admission, ethics, legitimacy." We collected all ethically relevant elements used in the author's justifications for or against coercive measures limiting freedom of movement (e.g., values, rights, practical considerations, relevant feelings, expected attitudes, risks of side effects), and coded, and ordered them into categories. Results: Some reasons provided in the literature are presented as justifying an absolute prohibition on coercion; they rely on the view that some fundamental rights, such as autonomy, are non-negotiable. Most ethically relevant elements, however, can be used in a balanced weighting of reasons to favor or reject coercive measures in certain circumstances. Professionals mostly agree that coercion is only legitimate in exceptional circumstances, when the infringement of some values (e.g., freedom of movement, short-term autonomy) is the only means to fulfill other, more important values and goals (e.g., patient's safety, the long-term rebuilding of patient's identity and autonomy). The results of evaluations vary according to which moral elements are prioritized over others. Moreover, we found numerous considerations (e.g., conditions, procedural values) for how to ensure that clinicians apply fair decision-making procedures related to coercion. Based on this analysis, we highlight vital topics that need further development. Conclusion: Before using coercive measures limiting freedom of movement, clinicians should consider and weigh all ethically pertinent elements in the situation and actively search for alternatives that are more respectful of patient's well-being and rights. Coercive measures decided upon after a transparent, carefully balanced evaluation process are more likely to be adequate, understood, and accepted by patients and caregivers.

Oyster Care: An Innovative Palliative Approach towards SPMI Patients

Oyster Care is the result of the search by caregivers in Flanders, Belgium, to develop quality care for patients with a Severe and Persistent Mental Illness (SPMI). This article offers a conceptual analysis of the Oyster Care model, based on experiences, analysis, and reflection of the authors, and on several examples. The starting point of the development of this new care model is the complex and difficult context of the care for SPMI patients. Their needs and suffering are very challenging on account of a wide variety of causes. At the same time they are in danger of being neglected by the care system. Paradoxically, the development and implementation of psychosocial rehabilitation in Belgian mental health care puts the care for these patients under pressure. In practice, they are often exposed to over- or under-treatment. Another aspect that has influenced the search for more qualitative care in cases of severe psychological suffering in general and palliative approaches in particular is the background of the legal regulation of euthanasia in Belgium. Oyster Care is an innovative form of the palliative approach and philosophy, tailored to the specific target group of SPMI patients. The caregivers create an "exoskeleton" or "shell" in which SPMI patients can "come to life": they are mainly dependent on the "external structure" they receive in order to function, rather than on the "internal structure" of their abilities. It is a dynamic approach that responds to the needs, possibilities and pace of each patient: within this safety, people can fold back or take new steps. Oyster Care is also a holistic care approach, based on four pillars: physical care adequately responding to the somatic impairments of these patients; psychological care changing the scope of therapy by focusing on mental comfort and wellbeing; social care providing a structure of daily activities and contacts; existential care enhancing the experience of life as valuable and meaningful. The wellbeing of patients is paramount and requires a range of interventions, such as a highly personal approach, a flexible dealing with rules, a great dose of creativity in everyday life, extensive expertise in somatic care, and specific attention to existential needs and the search for meaning. The development of this care model in a number of care units in Flanders increases the wellbeing of the patients and creates a significant positive dynamic among caregivers. However, more research and resources are needed to further develop and integrate this model.

A palliative care approach in psychiatry: clinical implications

Background

Traditionally, palliative care has focused on patients suffering from life-threatening somatic diseases such as cancer or progressive neurological disorders. In contrast, despite the often chronic, severely disabling, and potentially life-threatening nature of psychiatric disorders, there are neither palliative care units nor clinical guidelines on palliative measures for patients in psychiatry.

Main text

This paper contributes to the growing literature on a palliative approach in psychiatry and is based on the assumption that a change of perspective from a curative to a palliative approach could help promote patient-centeredness and increase quality of life for severely ill patients in psychiatry as well as in somatic medicine. To exemplify this, we offer three different clinical scenarios: severe and enduring anorexia nervosa, treatment-refractory schizophrenia, and chronic suicidality and persistent self-injury in borderline personality disorder.

Conclusion

We emphasize that many typical interventions for treatment-refractory psychiatric disorders may indeed be of a palliative nature. Furthermore, introducing traditional features of palliative care, e.g. so-called goals of care conversations, could aid even further in ensuring that caregivers, patients, and families agree on which treatment goals are to be prioritized in order to optimize quality of life in spite of severe, persistent mental disorder.

Attitudes toward assisted suicide requests in the context of severe and persistent mental illness: A survey of psychiatrists in Switzerland

Objective

Switzerland is among the few countries worldwide where a request for assisted suicide (AS) can be granted on the basis of a primary psychiatric diagnosis. Psychiatrists play an increasingly important role in this regard, especially when the request for AS arises in the context of suffering caused by severe and persistent mental illness (SPMI). The objective of the survey was to assess general attitudes among psychiatrists in Switzerland regarding AS requests from patients with SPMI.

Method

In a cross-sectional survey of 1,311 German-speaking psychiatrists in Switzerland, participants were asked about their attitude to AS for patients with SPMI, based on three case vignettes of patients diagnosed with anorexia nervosa, treatment-refractory depression, or severe persistent schizophrenia.

Result

From a final sample of 457 psychiatrists (a response rate of 34.9%) whose mean age was 57.8 years, 48.6% of respondents did not support access to AS for persons diagnosed with SPMI, 21.2% were neutral, and 29.3% indicated some degree of support for access. In relation to the case vignettes, a slightly higher percentage of respondents supported the patient's wish to seek AS: 35.4% for those diagnosed with anorexia nervosa, 32.1% for those diagnosed with depression, and 31.4% for those diagnosed with schizophrenia.

Significance of results

Although a majority of the responding psychiatrists did not support AS for SPMI patients, about one-third would have supported the wishes of patients in the case vignettes. In light of the increasing number of psychiatric patients seeking AS and the continuing liberalization of AS practices, it is important to understand and take account of psychiatrists’ perspectives.

Acceptability of palliative care approaches for patients with severe and persistent mental illness: a survey of psychiatrists in Switzerland

BACKGROUND

Some patients develop severe and persistent mental illness (SPMI) which is therapy-refractory. The needs of these patients sometimes remain unmet by therapeutic interventions and they are at high risk of receiving care that is inconsistent with their life goals. Scholarly discourse has recently begun to address the suitability of palliative care approaches targeting at enhancing quality of life for these patients, but remains to be developed.

METHOD

A cross-sectional survey asked 1311 German-speaking psychiatrists in Switzerland (the total number of German-speaking members of the Swiss Society for Psychiatry and Psychotherapy) about the care of SPMI patients in general, and about palliative care approaches in particular. 457 (34.9%) returned the completed survey. In addition, participants were asked to evaluate three case vignettes of patients with SPMI.

RESULTS

The reduction of suffering and maintaining daily life functioning of the patient were rated as considerably more important in the treatment of SPMI than impeding suicide and curing the underlying illness. There was broad agreement that SPMI can be terminal (93.7%), and that curative approaches may sometimes be futile (e.g. 72.4% for the anorexia nervosa case vignette). Furthermore, more than 75% of the participating psychiatrists were in favour of palliative care approaches for SPMI.

CONCLUSIONS

The results of the present study suggest that the participating psychiatrists in Switzerland regard certain forms of SPMI as posing high risk of death. Additionally, a majority of respondents consider palliative care approaches appropriate for this vulnerable group of patients. However, the generalizability of the results to all psychiatrists in Switzerland or other mental health professionals involved in the care of SPMI is limited. This limitation is important considering the reservations towards palliative care in the context of psychiatric illness, mainly because of the association with death and futility. Palliative care approaches, however, are applicable in conjunction with other therapies intended to prolong life. A next step could be to involve service users and develop a consensus of what palliative care might encompass in SPMI. A framework for identifying which patients might benefit from palliative care, should be explored for the future development of care for SPMI patients.

[Integrated Complex Treatment for Extreme Anorexia Nervosa; An Interdisciplinary Treatment Concept of the University Hospital Zurich]

Integrated Complex Treatment for Extreme Anorexia Nervosa; An Interdisciplinary Treatment Concept of the University Hospital Zurich Abstract. The serious physical mental and psychosocial morbidity due to anorexia nervosa is often perceived by sufferers as less serious than from their environment. Doctors and other healthcare professionals are therefore confronted with the difficulty that urgent medical treatment is considered as unnecessary or even threatening by those affected. Although patients with anorexia nervosa usually wish to improve their condition, they are usually only able to tolerate treatment aimed at normalizing eating behavior and gaining weight in response to high external pressure. In view of this situation, an interdisciplinary team with experience in these treatments is required to treat these patients. Close cooperation is necessary to ensure a supporting treatment framework.

Towards a palliative care approach in psychiatry: do we need a new definition?

Psychiatry today is mainly practised within a curative framework. However, many mental disorders are persistent and negatively affect quality of life as well as life expectancy. This tension between treatment goals and the actual illness trajectory has evoked a growing academic interest in 'palliative psychiatry', namely the application of a palliative care approach in patients with severe persistent mental illness. Recently, Trachsel et al presented a working definition of palliative psychiatry. This first official attempt to capture the concept is based on WHO's widely accepted definition of palliative care but modified and limited to include only severe persistent psychiatric illness. While this is a welcome step in the discussion on palliative care approaches in psychiatry, it also opens up for new questions. One of the most evident is whether psychiatry actually needs its own definition of palliative care or, put differently, whether there is something about mental disorders that differs so radically from other medical conditions that it calls for a separate definition. We acknowledge the need to discuss the goals of psychiatric care in patients with severe persistent psychiatric illness. However, we question whether a separate definition of palliative care exclusive to psychiatry is the right way to go. In this paper, we discuss why.

End-of-Life Care Preferences in Patients with Severe and Persistent Mental Illness and Chronic Medical Conditions: A Comparative Cross-Sectional Study

OBJECTIVES

Physicians rarely engage severe and persistent mental illness (SPMI) patients in end-of-life care discussion despite an increased risk of debilitating medical illnesses and mortality. Access to quality palliative care and medical assistance in dying (MAID) has become a priority in Canada and many jurisdictions. In this study, we compared SPMI and chronic medically ill (CMI) patients' end-of-life care preferences and comfort level with end-of-life care discussion, and identified potential predictors of interest in MAID.

DESIGN

Comparative cross-sectional study.

SETTING

Hospital-based.

PARTICIPANTS

We recruited 106 SPMI and 95 CMI patients at the Jewish General Hospital, Canada. Patients aged ≥40 years, without severe cognitive impairment, able to communicate in English or French and provide written informed consent were included.

MEASUREMENTS

Attitudes towards pain management, palliative sedation, MAID, and artificial life support were collected with the Health Care Preferences Questionnaire. Adjusted odd ratios (aOR) were calculated for each end-of-life care intervention. Comfort with discussion was rated on a Likert scale. A stepwise regression analysis was performed to identify predictors of interest in MAID.

RESULTS

SPMI was not correlated to any end-of-life care intervention, except for MAID where SPMI patients were less likely to support its use (aOR: 0.48, 95% CI: 0.25-0.94, p = 0.03). Religiosity was also correlated with interest in MAID (aOR: 0.14, 95% CI: 0.06-0.31, p < 0.001). Patients in both groups were comfortable talking about end-of-life care.

CONCLUSIONS

SPMI patients are able to voice their end-of-life care preferences, and contrary to some fears, do not want MAID more than CMI patients.

Palliative psychiatry for severe persistent mental illness as a new approach to psychiatry? Definition, scope, benefits, and risks

BACKGROUND

As a significant proportion of patients receiving palliative care suffer from states of anxiety, depression, delirium, or other mental symptoms, psychiatry and palliative care already collaborate closely in the palliative care of medical conditions. Despite this well-established involvement of psychiatrists in palliative care, psychiatry does not currently explicitly provide palliative care for patients with mental illness outside the context of terminal medical illness.

DISCUSSION

Based on the WHO definition of palliative care, a, a working definition of palliative psychiatry is proposed. Palliative psychiatry focuses on mental health rather than medical/physical issues. We propose that the beneficiaries of palliative psychiatry are patients with severe persistent mental illness, who are at risk of therapeutic neglect and/or overly aggressive care within current paradigms. These include long-term residential care patients with severe chronic schizophrenia and insufficient quality of life, those with therapy-refractory depressions and repeated suicide attempts, and those with severe long-standing therapy-refractory anorexia nervosa. An explicitly palliative approach within psychiatry has the potential to improve quality of care, person-centredness, outcomes, and autonomy for patients with severe persistent mental illness.

CONCLUSIONS

The first step towards a palliative psychiatry is to acknowledge those palliative approaches that already exist implicitly in psychiatry. Basic skills for a palliative psychiatry include communication of diagnosis and prognosis, symptom assessment and management, support for advance (mental health) care planning, assessment of caregiver needs, and referral to specialized services. Some of these may already be considered core skills of psychiatrists, but for a truly palliative approach they should be exercised guided by an awareness of the limited functional prognosis and lifespan of patients with severe persistent mental illness.