How Should MLP Clinicians and Attorneys Help Veterans Secure Disability Benefits When Health Records Documentation Is Insufficient?

This case commentary considers unique features of medical-legal partnerships (MLPs) in the Veterans Health Administration that may potentially mediate and minimize ethical tensions that may arise in MLP collaborations involving diagnosing and documenting disability.

C-L Case Conference: Assessment of Dispositional Capacity in Medically Complex Patients.

We present the case of a 76-year-old male with mild cognitive impairment and delirium who was referred to consultation-liaison psychiatry for an assessment of capacity to choose discharge. Cases involving "dispositional capacity" are complex and increasingly frequent, with momentous consequences for patients and their families, but are rarely discussed in the literature. In this article, experts in functional assessment, cognition, and ethics provide guidance for this commonly encountered clinical scenario based on their experience and available literature. We review the content and formulation of occupational and physical therapy assessments and their utility to the consultation-liaison psychiatrist. We also examine the relationship of cognitive impairment to decisional capacity and offer suggestions on a structured approach to evaluation. Finally, we discuss the ethical and systemic considerations of dispositional capacity and explore potential pitfalls that can lead to interprofessional conflict and missed opportunities in patient care.

Limits of advance directives in decision-making around food and nutrition in patients with dementia.

Advance directives are critically important for capable individuals who wish to avoid the burdens of life-prolonging interventions in the advanced stages of dementia. However, this paper will argue that advance directives should have less application to questions about feeding patients during the clinical course of dementia than often has been presumed. The argument will be framed within the debate between Ronald Dworkin and Rebecca Dresser regarding the moral authority of precedent autonomy to determine an individual's future end-of-life care plan. We will use a brief analysis of the positions taken in two important papers that come out of the Dworkin/Dresser debate and a hypothetical patient, John, who will be followed from diagnosis of dementia to death, to show how advance directives should apply to key points in the progression of his disease, particularly in relation to food and nutrition.

Is There a Case for Palliative Care Addiction Psychiatry?

This commentary on a case suggests how palliative care psychiatry can facilitate compassionate resolution of ethical conflicts in end-of-life care decision making with persons with substance use disorders.

Veterans Health Administration response to 2021 recall of Philips Respironics devices: A case study.

This case study describes, for the time frame of June 2021 through August 2022, the U.S. Veterans Health Administration (VHA) organizational response to a manufacturer's recall of positive airway pressure devices used in the treatment of sleep disordered breathing. VHA estimated it could take over a year for Veterans to receive replacement devices. Veterans awaiting a replacement faced a dilemma. They could continue using the recalled devices and bear the product safety risks that led to the recall, or they could stop using them and bear the risks of untreated sleep disordered breathing. Using a program monitoring approach, we report on the processes VHA put in place to respond to the recall. Specifically, we report on the strategic, service, and operational plans associated with VHA's response to the recall for Veterans needing replacement devices. In program monitoring, the strategic plan reflects the internal process objectives for the program. The service plan articulates how the delivery of services will intersect the customer journey. The operational plan describes how the program's resources and actions must support the service delivery plan. VHA's strategic plan featured a clinician-led, as opposed to primarily legal or administrative response to the recall. The recall response team also engaged with VHA's medical ethics service to articulate an ethical framework guiding the allocation of replacement devices under conditions of scarcity. This framework proposed allocating scarce devices to Veterans according to their clinical need. The service plan invited Veterans to schedule visits with sleep providers who could assess their clinical need and counsel them accordingly. The operational plan distributed devices according to clinical need as they became available. Monitoring our program processes in real time helped VHA launch and adapt its response to a recall affecting more than 700,000 Veterans.

Tertiary Healthcare Ethics Consultation: Enhancing Access to Expertise.

Tertiary healthcare ethics (HCE) consultation occurs when an HCE consultant at a healthcare facility requests guidance from one or more senior HCE consultants who are not members of that facility's HCE consultation service. Tertiary HCE consultants provide advanced HCE guidance and/or mentoring to facility (secondary) HCE consultants, mirroring healthcare consultation in clinical practice. In this article, we describe advantages and challenges of providing tertiary HCE consultation through a hub-and-spoke model administered by a national integrated HCE service.