Should a psychiatrist report a bus driver's alcohol and drug abuse? An ethical dilemma.

Denial of alcohol or drug abuse, and of its possible consequences, can complicate medical and psychiatric care. We present the case of an HIV-positive bus driver with substance abuse who initially denied ongoing use of alcohol and of other drugs, but later admitted to both. The psychiatrist's duty to protect the patient's confidentiality, coupled with concerns about public safety, created an ethical dilemma. In discussing this dilemma we stress the importance of preserving confidentiality, both to facilitate treatment and also to further the safety of others.

A combined ethics & psychiatric consultation.

A case presentation is used to illustrate how psychiatrists can contribute to clinical ethics. A 75-year-old man with end-stage COPD was admitted to the ICU. His condition deteriorated and he lost decision-making capacity without expressing his wishes about end-of-life care. Although he no longer needed care in the ICU his surrogate decision-maker objected to his being transferred. Seven months after the patient's admission an ethics consultation was carried out by a psychiatrist-ethicist. The following issues are discussed, elaborating on points previously made by the authors [1,2]: the absence of an advance directive, surrogate decision-making, the allocation of ICU beds, guidelines for discharge from the hospital, the lateness of the ethics consultation, and the interweaving of ethical questions with psychiatric factors. The psychiatrist-ethicist was ideally suited to address all these issues and to make a significant contribution to the care of the patient and his family.

Psychiatric consultations and ethics consultations. similarities and differences.

Although consultation-liaison psychiatry and clinical ethics both developed largely in response to the problems engendered by the new medical technology and the dilution of the traditional doctor-patient relationship, they represent distinct fields that rely on different, but overlapping, domains of expertise. To be effective, ethics consultants often need to augment their own background with psychiatric knowledge and skills. Consultation-liaison psychiatrists are well prepared to contribute to clinical ethics but cannot serve effectively as ethics consultants without additional education and training. Several case examples are presented to elucidate these points and to illustrate the similarities and differences between psychiatric consultations and ethics consultations.

An annotated bibliography for ethics training in consultation-liaison psychiatry.

The expanding field of bioethics has created a need in psychiatry for rapid access to the complex bioethics literature. This is especially true in consultation-liaison work. An annotated bibliography was created by a task force of the Academy of Psychosomatic Medicine charged with exploring how psychiatrists function on bioethics committees. The bibliography is organized into headings that reflect how bioethical problems came to the attention of psychiatrists. Introductory references allow the reader an overview of the history of bioethics and a selection of useful textbooks. References are provided explaining how ethical principles are used. References are also organized by areas of medical work frequently visited by consultation-liaison psychiatrists.

Depression and the right to die.

There is a complex relationship between depression and the capacity to forego life-sustaining treatment. On the one hand, the courts have recognized a constitutionally protected right to die for competent persons; on the other hand, psychiatrists have tended toward the presumption of incompetence on the part of anyone who refuses lifesaving treatment. This traditional psychiatric viewpoint stems from experience with many patients whose wish to die disappears when their depression is successfully treated.

Patient autonomy and undertreatment of critical disease.

Respect for patient autonomy may cause conflict with the treatment plan. Acquiescence to a patient's irrational demands may have irreversible, if not fatal, consequences. Psychiatric and ethical consultation can help patients make informed choices.

Risperidone-induced neuroleptic malignant syndrome.

OBJECTIVE: To describe a patient with neuroleptic malignant syndrome (NMS) induced by risperidone, an atypical antipsychotic, and to review the available literature related to risperidone-associated NMS. DATA SOURCE: Case report information was obtained from the resident physician and medical records. MEDLINE and Index Medicus were searched to obtain literature published between 1960 and 1995. DATA SYNTHESIS: We report an adolescent boy who developed NMS after treatment with risperidone. Risperidone therapy was started after unsuccessful treatment and development of extrapyramidal adverse effects with haloperidol. The patient demonstrated the classic tetrad of fever, generalized skeletal muscle rigidity, altered mental status, and autonomic dysfunction. Risperidone was discontinued and the patient recovered after a prolonged hospital course with supportive management. CONCLUSIONS: Clinicians are cautioned about the possibility of NMS with risperidone.

Should general hospitals accept involuntary psychiatric patients? A panel discussion.

The issue of whether involuntary patients can be treated safely and effectively on inpatient psychiatry units of general hospitals is addressed from several points of view. Parallels are drawn between contemporary reform efforts and 19th century hospital psychiatry, and the danger of repeating errors of the past is pointed out. An account follows, illustrating the recent planning process for mental health care in Massachusetts and recommending the active participation of psychiatrists in that process. Also discussed are the differences in the process of establishing a treatment alliance with voluntary and involuntary patients. The practical considerations in the development of a locked unit in a general hospital area explored, with respect to its effect on reimbursement, the private practice model, and the length and appropriateness of stay. In conclusion, the shared concern is stated that, in respect to making the transition from one system of care to another, safeguards be built in to protect and expand good treatment.

The "least restrictive environment": from rhetoric to practice.

During the past 10 years, more and more general hospitals have opened psychiatric units, many of which represent the best of modern hospital psychiatry. Therapeutic success on these units is based on control of admissions as well as on clinical programs. Pressure from the State to admit involuntary patients, recently justified by the doctrine of the "least restrictive environment," threatens to erode the quality of treatment now being provided. The concept of "least restrictive environment" is ambiguous and sometimes misleading. The treatment of involuntary psychiatric patients in general hospitals, in order to be safe and effective, requires the resolution of legal, clinical, financial, and architectural issues, as well as problems in the relationship between psychiatric units and other areas of the general hospital.

Involuntary admissions to general hospitals: progress or threat?

For a variety of reasons, general hospitals are being asked to accept both involuntary admissions and patients who are difficult to manage safely on an unlocked unit. The author considers some of the programmatic, legal, architectural, and economic issues that must be resolved if this challenge is to be met successfully. He also addresses the public relations issues and the impact on psychiatry's liaison to general medicine. He believes that if psychiatric services in general hospitals are broadened thoughtfully and deliberately, with careful attention to the clinical needs of all patients, the over-all quality of psychiatric care can be enhanced. Otherwise there is risk of destroying the best of modern hospital psychiatry.