The illusion of patient choice in end-of-life decisions.

After passage of the Patient Self-Determination Act and the Cruzan decision by the Supreme Court, honoring individual patient choice has become the primary means by which we have sought to improve the quality of life of the dying patient. However, the decision-making capacity of the dying patient is usually compromised, and advance directives have not consistently improved the dying process. We respect patient autonomy in order to respect the patient as a person; patient autonomy should be respected to the degree that it is intact. When autonomy is significantly diminished, as it usually is in dying patients, respecting autonomy reconstructed from documents or proxies may not be the best way to respect the dying person. We rather need to seek social consensus about when patients are dying, the nature of a "good death," and when it is preferable to a longer life.     

Reibl v. Hughes: the consent issue

Inviolability of the person is the basic principle underpinning the concept of consent to treatment. Although it is not a new concept, consent has become a major medico-legal issue because of a shift, within the doctor/patient relationship, towards more autonomy for the patient and less paternalism from the doctor. This change has been given further impetus by legal decisions such as Reibl v. Hughes and Hopp v. Lepp. In this paper the author reviews the nature of the changes and the impact of the legal decisions on the doctor/patient relationship. He concludes that a legal approach to consent is sterile if it is a substitute to open communication between the doctor and the patient, or to their acceptance of a principle of "equality of two participants". Consent is based on the basic principal of the inviolability of the person, that is, the right, at all times, of every individual not to have his body tampered with without his permission or agreement, and to be the whole decision-maker on matters that affect his physical integrity. This right is not absolute: it may be abrogated by the state for health or judicial reasons, or the person may not be in a position to exercise it, such as when unconscious or because of mental disability. This paper will review present Canadian laws on consent. It will contrast the legal approach to consent to the ethical-humanistic approach which could be developed within the context of the doctor/patient relationship.     

Medical decision making in the vegetative state: withdrawal of nutrition and hydration

Withdrawal of nutrition and hydration, is a difficult and sensitive issue for all those working with people in the vegetative state. There are arguments against the decision to withdraw any treatment that might result in the patient deteriorating or dying. These arguments include the view that all life is worth having, that we can never be certain that the patient is not aware, and concerns that there may be new scientific developments in the future from which the patient would benefit. Others argue that the patient has no interests in life; that it is undignified, if not an assault, to insert tubes into a permanently unconscious person; that very few people would want to survive in this condition; and that it prevents loves ones from grieving. These strongly held opposing views can make clinical decision making very difficult for the clinician. Once the decision has been made to withdraw treatment then the clinician has to be certain that the patient is in the vegetative state, that there are no factors preventing the patient demonstrating awareness, that he has received expert assessment and treatment, and that the prognosis for lack of recovery is as clear as it can be. It is important to support family and staff throughout this process. The concept of withdrawal of nutrition and hydration is a sensitive issue and clinicians can expect to be considered as not acting in the patient's best interest whatever decision is taken.     

JAKOB narrative analysis: The psychodynamic conflict as a narrative model

Abstract

When a patient tells a story during psychotherapy sessions, it is both a mutual interaction between patient and therapist and a presentation of personal experience. The patient calls up and re-creates a biographical occurrence and puts it before a listener for viewing, enacting it verbally in the perspective of wish fulfillment and anxiety coping. JAKOB narrative analysis, situated in the field of psychoanalytical and narrative analytical research, is an encoding-supported qualitative instrument for the systematic reconstruction of verbal everyday narratives in the context of psychotherapeutic processes. In this study, the JAKOB narrative analysis is described in detail with the aid of an example narrative, put in relation to the therapeutic process, and discussed critically from a methodological viewpoint.     

The price of a gift: an approach to receiving gifts from patients in psychiatric practice

When a patient or patient's family presents a psychiatrist with a gift, the clinician is challenged to maintain appropriate professional boundaries but have the flexibility to respond with warmth and appreciation. The psychiatrist must consider such factors as the intention of the gift, its value to the patient, and the anticipated effect of accepting or refusing it on the patient and the treatment. Psychiatric practitioners are ethically obligated to consider patients' best interests when deciding about how to handle the offer of a gift. Ethical deliberations about such situations occur on a case-by-case basis and require careful analysis of how to promote the patient's best interest while adhering to professional ethics. In this article, members of the McLean Hospital Ethics Committee present a pragmatic model for managing the presentation of a gift from a patient or a patient's family member. The pragmatic model, which focuses on the practical results of accepting or declining the gift, minimizes the risk of exploiting the patient by accepting a gift or hurting the patient by declining it. We present five clinical cases that raise ethical dilemmas concerning patient gift giving in psychiatry and discuss each case from the standpoint of the pragmatic model.     

A Propos du Changement du Caractère Épileptique

Until today the so-called “Haftsyndrom” has been considered as an expression of the organic process of brain which is produced with the chronic course of epilepsia and has been understood as the inevitable and irreversible status. Being pointed out by authors such as v.V. Weizsäcker, A. Matthes, D. Janz et al., it is not necessarily a product of the epileptic organic change, but it is owing to the therapeutic relations between the patient and the doctor and the people in the world that surrounds the patient. The patient who finds himself in a particular status called epilepsia forms gradually irreversible character in the unnatural distorted human-relations that he holds in the course of his long life. The attack itself is extremely conditioned by situation and, at the same time, the status called the change of character or die Wesensänderung is also, in our opinion, a form of prolonged and conditioned attitude that the patient takes. The patient hangs on the environment-world that can not accept him and becomes obstinately stickle. He is compelled to take a form of life that permits himself to be admitted. The form of his attitude toward the people who accept him is hardly characteristic of him, but is merely an attitude of reaction and his response to the world that surrounds him. He does not only take an attitude in which we can assimilate him. Some characteristics with which the patient is evaluated as a difficult being are a neurotic way to defend himself against the world that surrounds him and a means to protect his own value. Thus, it is necessary to apply a psychotherapy in a broad sense as soon as possible in order to prevent the development of this status. Also it gives us an occasion to reflect again upon what is the change of character. The author presents two cases discussing such problems from the psychotherapeutic point of view.     

Between compliance and freedom: the patient's statement

According to the patient, obtaining a good compliance is related to a good relationship with his practitioner; this relationship is directly connected to being a good listener for the patient, and not only for their symptoms. If the individual motivation is very important at the beginning, it will be itself greatly influenced by the relationship between the practitioner and the patient. It is one of the rare factors with a positive correlation with compliance, that's what almost all of the researches on medical psychology have observed. Once the problem is sumed up, it's the turn to speak for the patient, who explains how he considers compliance.     

Focussing on quality of life in treatment

There are widespread calls for the implementation of outcomes management in mental health services, which involves routinely assessing individual patient outcomes to analyse the effectiveness of treatment. The emphasis in outcomes management is on aggregating outcome data on the level of groups and services and feeding the results back to commissioners, clinicians and managers to inform their decisions on service development and funding. The most important outcome criterion in mental health service research is quality of life, which is also the 'centrepiece' of outcomes management. In several countries, there are plans to implement the main component of outcomes management, i.e. routine outcome assessment, requiring clinicians to routinely assess patient outcome. However, valid data will only be collected if it is worthwhile for clinicians and patients at the level on which it is collected, i.e. the individual patient level. Concurrent assessment and feedback of outcome data to the clinician and patient so that the information can be used to inform treatment activities might make it worthwhile. A European multi-centre randomized controlled trial is currently underway to test the effect of such an intervention in the treatment of psychotic illness. Keyworkers will systematically elicit patients' views on their quality of life, treatment satisfaction and needs for additional/different care over 1 year. It is hypothesized that the intervention will improve patient outcome by prompting explicit discussion about reasons for progress--and lack of progress--in treatment as a basis for further treatment decisions. If the intervention is effective, it is hypothesized that the effect will be mediated by more appropriate treatment decisions and/or a better therapeutic relationship. Focussing on the patient's perspective in the therapeutic interaction may also facilitate patient involvement in decision-making. Finally, outcomes management is still a technical term, which could benefit from further specification and development in order to exploit its potential for improving treatment processes in mental health care.     

The interface between psychoanalytic theory and the practice of psychoanalysis

In my opinion there is invariably an element of contamination in tandem with elucidation. The complex interface between the theoretical and practical sides of the analytic process requires a kind of "double bookkeeping." This results from our need to put our theoretical game plan or strategy on hold when the patient has the floor. This holding pattern prevails when we respond to the patient within the clinical interactional field. Once we take the lead for an exploration, or interpretation, our attention is focused on the impact of our question or comment on the patient. In turn, we need to respond to the patient's data without pigeonholing. As practicing analysts, we function as professionals without wearing a particular persona akin to the masks of antiquity. We are who we are and we operate in an ambience of resonance with the patient. Self-monitoring is a basic requirement for our work. None of us is free of foibles and peculiarities that the patient notices sooner or later. A degree of pluralism does not prevent us from using a theoretical frame of reference to enable us to have a flexible strategy geared to the individual patient. As noted earlier, in the quest for knowledge our assumptions regarding reality are constantly challenged. In that respect, psychoanalytic and scientific theories are more alike than different when we use them as bases for knowledge; they make it harder to tolerate those occasions when we somehow come to know what works without knowing factually why it works the way it does.(ABSTRACT TRUNCATED AT 250 WORDS)     

The conflict between accountability and confidentiality in Medicare's access to psychiatrists? notes

OBJECTIVE: The aims of this paper were to identify a conflict between psychiatrists? obligations regarding patient confidentiality and Medicare's auditing procedures, and to examine potential resolutions to the conflict. CONCLUSION: While it is reasonable for Medicare, as a taxpayer-funded instrumentality, to require documentary evidence to substantiate and justify claims, such a requirement constitutes a significant breach of patient confidentiality. Obtaining patient consent appears to be the only ethical resolution of the issue.     

Current medico-legal issues -- a psychiatrist's view.

The present challenges in medicine indicate clearly that a fuller partnership between patient and doctor is being evolved, without secret or unshared clauses. When a satisfactory relationship develops, it not only satisfies medico-legal requirements, but also fulfills the basic needs of excellent practice. The education of the patient and his family is an important part of the treatment process. The physician must consider and evaluate symptom, disease, and the patient as a person. It is the failure to establish a balanced equilibrium of these elements in any program of patient care, which give rise to crisis in patient-physician relationships, from which legal actions originate.     

Inverted vision after frontal lobe disease

A case of bifrontal abscesses is reported. The patient claimed that he sometimes saw the world as if it were upside-down. A review of the literature reveals that, since 1805, 21 similar cases have been documented. The present case is unusual in that the neuropsychological status of the patient is investigated in some detail, and in that it seems to be the first report of inverted vision in a case of frontal lobe disease.     

Treatment of psychological factors in a child with difficult asthma: a case report

Difficult asthma is defined as the persistence of asthma symptoms, abnormal pulmonary function showing airway obstruction, and continued requirement for short-acting bronchodilator therapy, despite adequate treatment with inhaled corticosteroids. It calls for a thorough evaluation of the patient to look into alternate and complicating diagnoses. The authors report a case of a 9-year-old patient with difficult asthma who failed to respond to conventional therapy. Although it was recognized that he had a number of potential medical complicating factors including allergies, chronic sinusitis, and gastroesophageal reflux, a psychological intervention using hypnosis ultimately appeared to help alleviate his symptoms completely. Thus, psychological evaluation and intervention should be considered early in the course of management of a patient with difficult asthma, because it may help avoid time-consuming and expensive investigations of potential complicating factors, and it may yield rapid improvement in the patient's clinical condition.     

Cryoglobulinemic vasculitis in a patient with CREST syndrome

Cryoglobulinemic vasculitis is a rare entity. Although it has been reported in diffuse systemic sclerosis, it has not been reported in calcinosis, Raynaud’s phenomenon, esophageal dysmotility, sclerodactyly and telangiectasia (CREST) syndrome. We report a patient with cryoglobulinemic vasculitis with CREST syndrome who did not have typical clinical features of vasculitis. This 58-year-old woman presented with mild generalized weakness and a diagnosis of CREST syndrome, which included Raynaud’s syndrome, dysphagia and telangiectasias. She was positive for serum cryoglobulins, which led to a sural nerve biopsy. The biopsy results were consistent with cryoglobulinemic vasculitis. Cryoglobulinemic vasculitis has not been previously reported in CREST syndrome to our knowledge. Additionally, the patient also had limited clinical symptoms. Our patient displays the importance of checking for cryoglobulins and obtaining a nerve biopsy when the serum is positive. Both of these diagnostic tests were integral for directing appropriate treatment for this patient.     

Detection and Triage of Urinary Incontinence Problems in a Psychiatric Practice

Urinary incontinence is a common complaint in women, and the incidence increases with age. Since continence is the result of the interaction of several neurologic, anatomic, and physiologic factors, it may be affected by a number of pathological conditions, physical changes, or pharmacologic agents. Psychiatrists are often the only physicians caring for women in an ongoing fashion. But patients are often embarrassed to discuss incontinence unless directly questioned. Thus, it is reasonable for a psychiatrist to ask about this problem, take a history to help determine whether the patient will respond to simple therapy or whether she may require referral. This paper will define the types of incontinence and the etiologic factors that may be the cause and will offer suggestions as to how the psychiatrist can evaluate the patient initially and decide on appropriate disposition of the patient with this problem.     

Does anesthesia cause loss of consciousness?

Although about 30 million operations carried out under general anesthetic are routinely performed each year in the USA alone, it is not possible to determine reliably whether or not a given anesthetized patient is conscious during surgery. As a result, some patients may be either partially aware during the operation or may be able to recall some aspects of it afterwards. It is therefore crucial to develop some experimental means to evaluate the state of consciousness of the anesthetized patient. Recent developments suggest that 40 Hz neuronal oscillations might help to solve this problem.     

Mrs. Lloyd Merrill

The nature of therapeutic action is described in the experience-near terms of surprise, shock, and dread, and more theoretically in terms of dissociative processes. Dissociated experience is not available through the ordinary analytic process of uncovering and exploration because it cannot be reflected on and is inevitably incompatible with the treatment relationship as it stands. It can only find expression through enactments and, in the process, obliterates other perspectives or realities that are likely to have been hard-won by the analytic couple. I suggest that in the course of an analysis, when patient and analyst achieve deep mutual trust, a special set of circumstances evolves in which there is a change in the way the patient uses dissociation. The patient actively seeks out those aspects of the analyst's behavior or person that permit reexperiencing of the traumatic past and dissociates the other aspects of the analytic relationship involving confidence, goodness, and trust. This is not a defensive use of dissociation and in fact, if we know how to work with it, is potentially the conduit through which new experience becomes available within the transference. Working with it successfully entails the analyst encountering the shock of being altered in entirely unanticipated ways and the dread of it being permanent. A detailed case example is used to elucidate these ideas.     

The “Patient Presentation:” The Evolutions of a Practice,of Its Objectives,and of Its Effects on Training

ObjectivesThrough a review of the history of patient presentations and changes to this system, we will try to situate its function and challenges, particularly with regard to its effects on the training of professionals. The articulation of these effects with the necessary ethical questions raised by this practice will be highlighted.MethodThe review of the French-language literature on the practice of patient presentations makes it possible to note its permanence since the origins of psychiatry, its multiple challenges, the risks it has encountered over the course of its history, and the consequent changes that have resulted from it. A personal experience of patient presentations at the Centre Hospitalier Sainte-Anne over more than twenty years allows us to emphasize the essential elements of this exercise.ResultsPracticed mainly in recent years by psychoanalysts, the system of patient presentations has been considerably modified by taking into account the registers of language, speech, and the transference. The control or supervisory dimension also becomes a central function of this practice. This subversion makes it possible to significantly advance the controversies that run through its history. It also highlights its instructive effects, which, far from being limited to a pedagogical demonstration to inexperienced practitioners, involve practitioners in a place that allows them to question their position as well as their action, in their daily practice.DiscussionThe diversity of patient presentation systems, the variety of circumstances that led to their implementation in hospital services, the variable place they occupy in the organization of care, and the unequal interest that they can arouse on the part of healthcare teams justify identifying the essential benchmarks that make this practice so specific. The articulation of the three distinct places of the patient, the examiner, and the public – through the distinct knowledge attributed to each of these places – makes it possible to propose a reading of the structure of these presentations to examine their effects on the training of practitioners, as well as on clinical research.ConclusionIf clinical practice is developed and transmitted “at the patient's bedside” and in the dialogue between practitioners, then the presentation of the patient is one of the key places where clinical practice is developed. The ethical questions it raises thus constitute an opportunity for a renewal of the psychiatric clinic and its practice.     

Toxoplasmosis masquerading as a psychotropic side effect

When treating a patient with neuroleptics or tricyclic antidepressants, it is usually assumed that complaints of blurred vision can be ascribed to the anticholinergic side effects of these drugs. The authors present a patient treated with imipramine and trifluoperazine whose complaints of blurred vision led to the diagnosis of toxoplasma chorioretinitis.     

The Ineffable Articulated

Much clinical case reporting is an enactment that alters, distorts, and reconstructs the analytic process and the analysand's experiences. The analysand's voice in clinical literature tends to disappear, leaving the analyst writer as the potential ventriloquist in an illusionary one-person psychic space. This paper presents a fragment of a woman's journey through analysis, hearing it in the patient's voice as it presents itself in an e-mail correspondence between the patient and the analyst. In this correspondence, the patient writes about her experience with her first analyst (to whom the correspondence is addressed) and with a second analyst who had found her to be unanalyzable (and with whom she is in analysis while writing). The first analyst, the patient, and the first analyst's colleague are exploring various actors' contributions to the analytic process.