On the Edge of Life, II: House Officer Struggles Recorded in an Intensive Care Unit Journal

BACKGROUND: In a general hospital, few clinical settings match the intensity of the intensive care unit (ICU) experience. Clinical rotations in ICUs elicit and emphasize the struggles house officers face on a daily basis throughout their training. METHOD: These struggles were recorded by hundreds of residents in a journal maintained in one Medical ICU for the past 20 years. We systematically reviewed these unsolicited entries to develop categories that define and illustrate common stressors. RESULTS: Stressors for house officers include isolation, insecurity, care for the terminally ill, sleep deprivation, and long work weeks. CONCLUSION: By placing the struggles of house staff in context, trainees and their residency training programs can be prepared for the intensity of the experience and for work in clinical practice settings that follows completion of training.     

Orders not to resuscitate and the psychiatric hospital

In 1983, the President's Commission for the Study of Ethical Problems in Medicine recommended that all health care institutions be required to develop appropriate policies and procedures for withholding life-sustaining treatment from terminally ill patients. While such policies have been extensively debated, there has been little discussion of the problem in the psychiatric literature. Yet state mental hospitals handle many terminally ill patients, often without having clarified their medical responsibilities. This article focuses on Do Not Resuscitate (DNR) policies in psychiatric settings. It offers illustrative case examples and reviews the important principles and legal decisions that pertain to DNR policies. In hospitals that have no clearly defined medical standards, patients often receive inferior care. The need to develop DNR policies presents an opportunity to discover more thoughtful approaches to medical care in psychiatric hospitals.The author acknowledges the assistance of James Bakalar, J.D., Paul Litwak, J.D., and Jamie Benfield, J.D.     

The house officer and the dying patient: Attitudes, experiences, and needs

A survey of house staff who care for dying patients was conducted at a large medical center and demonstrated that house officers are aware of their discomfort in dealing with dying patients and their families but believe they do not avoid them. They strongly agreed with the use of the “no code” designation and believed the quality of life was the most important factor in making that decision. The house officer who has concerns about a dying patient is most likely to talk with another house officer. The survey highlights the needs of house staff for experienced resource people and informal programs dealing with the care of dying patients.     

A survey of signs, symptoms and symptom control in 30 terminally ill children

The notes of 30 terminally ill children with various diagnoses were searched for reports of symptoms that had occurred during their last month of life. All had stayed at Helen House, a hospice for children, for part or all of that time. The results were analysed for symptom frequency and resistance to treatment. Over four-fifths of the children were recorded as having pain in the last month of life. In a smaller number, symptoms such as muscle spasm and excessive secretions proved particularly difficult to control. The identification of symptoms in brain-damaged and young children, and the control of some of the more resistant symptoms, are discussed.     

Treatment of Depression at the End of Life: Clinical and Ethical Issues

The issue of "treatable depression" in terminally ill patients has been raised in discussions of physician-assisted suicide. However, the role of psychiatry in palliative care remains largely undefined. Studies have documented a major depression prevalence in hospitalized patients with acquired immunodeficiency syndrome (AIDS) and cancer of 17% to 36% and in terminally ill patients from 9% to 17%. No randomized, controlled trials of depression treatment in the terminally ill have been completed. Tricyclic antidepressants and selective-sertonin reuptake inhibitors (SSRIs) have been proven effective in randomized trials for major depression in patients with cancer or human immunodeficiency virus (HIV) infection. Psychostimulants have shown effectiveness by randomized trial in medical inpatients, but only by case series in the terminally ill. Randomized trials have shown the effectiveness of psychotherapies for depression in cancer (ie, cognitive behavioral) and HIV-infected patients (ie, interpersonal). An open trial suggests effectiveness for problem-solving therapy for terminally ill patients. In summary, the treatability of depression in the terminally ill remains to be proven by randomized trials.     

Teaching psychosocial issues to medical house staff: A liaison program on an oncology service

In a one-year controlled study, the authors assessed the impact of an active consultation-liaison teaching program on the attitudes of medical house officers toward psychosocial issues related to the care of oncology patients, consultation-liaison psychiatry, and its importance for them and their patients. Fifty medical interns, residents, and fellows, divided into a test group (N = 25) and a control group (N = 25), were followed during a one year period. A 52-item questionnaire was administered to test group subjects before and after a one- to two-month clinical rotation on the hematology/oncology service, and to the control group members at similar intervals. After their experience with consultation-liaison psychiatry, the test group members showed a significant positive change in the importance they placed upon psychiatric consultations, case presentations and the role of psychiatrists in the development of their attitudes toward the psychological case of cancer patients. The house officers also recorded significant positive changes in their attitudes toward the effectiveness and role of the consultation-liaison service in educating and assisting them in learning more about psychosocial issues. The control group demonstrated no significant change.     

Suicide among New York City police officers, 1977-1996

OBJECTIVE: The authors assessed the suicide rates of New York City police officers during a recent period. METHOD: The authors reviewed death certificates of active New York City police officers who died from 1977 through 1996 (N=668); age-, gender-, and race-specific suicide rates among New York City police officers and the city's residents were determined. RESULTS: The police suicide rate was 14.9 per 100,000 person-years, compared with a demographically adjusted suicide rate of New York City residents of 18.3 per 100,000 person-years. Suicide rates among male police officers were comparable to their reference population. Female police officers had a higher risk of suicide than female residents of New York, but the number of suicides of female police officers was small. CONCLUSIONS: The rate of suicide among New York City police officers is equal to, or even lower than, the suicide rate of the city's resident population.     

Nonconvulsive Status Epilepticus in the Critically Ill Elderly

Summary: Purpose: To describe the electrographic and clinical features of nonconvulsive status epilepticus (NCSE) in the critically ill elderly and to identify potential predictors of outcome.
Methods: We prospectively identified 25 episodes of altered mentation and NCSE in 24 critically ill elderly patients associated with generalized, focal, or bihemispheric epileptiform EEG patterns. Patients with anoxic encephalopathy were excluded.
Results: Of 25 hospitalizations, 13 (52%) resulted in death, and 12 (48%) patients survived to discharge. Death was associated with the number of acute, life-threatening medical problems on presentation (survivors, 1.8; fatalities, 2.8; p = 0.013) and with generalized EEG pattern (p = 0.017). Higher doses or greater number of antiepileptic drugs (AEDs) did not improve outcome. Treatment with intravenous benzodiazepines was associated with increased risk of death (p = 0.033). Ten patients with advance directives were managed outside the intensive care unit (ICU). Mean hospitalization was 39 days in the ICU group and 22 for those with advance directives (p = 0.017).
Conclusions: Severity of illness correlates with mortality in critically ill elderly patients with NCSE. Treatment with intravenous benzodiazepines may increase their risk of death. Aggressive ICU management may prolong hospitalization at considerable cost, without improving outcome. It is unclear whether NCSE affects outcome in the critically ill elderly or is merely a marker for severity of disease in predisposed patients. The benefits of aggressive therapy are unclear. Carefully controlled, prospective trials will be necessary to determine the best therapies for NCSE in the critically ill elderly and the appropriate role of the ICU in their management.     

Cigarette smoking in psychiatric settings: occupational health, safety, welfare and legal concerns

OBJECTIVE: In the current climate of growing concern for the harmful effects of cigarette smoking and passive smoking, the high prevalence of this activity within psychiatric settings can no longer be ignored. This paper reviews the findings of research in a public stand-alone psychiatric facility in South Australia where significant legal and occupational health, safety and welfare (OHSW) concerns were apparent for both patients and staff as a consequence of the strong culture of smoking in that setting. The aim of this paper is to raise awareness of this significant health and legal issue and to inform policy and practice change. METHOD: This paper reviews legal issues associated with smoking in psychiatric settings and presents relevant findings from previous studies in which in-depth interviews and observations in community and inpatient psychiatric settings were conducted. RESULTS: Significant legal and OHSW concerns were apparent for both patients and staff in all settings. The potential for future litigation was high. CONCLUSIONS: There are a number of legal and OHSW implications of continued smoking by staff and patients within mental health settings. Several administrative, clinical and cultural practices need to change within this system of care in order to improve overall patient wellbeing and to avoid the potential for litigation by patients and staff.     

The quality of life of chronic patients in a state hospital and in community residences

Amidst the controversy about the effects of deinstitutionalization, the well-being of the chronic mentally ill in different treatment settings remains unclear. This study examined objective and subjective quality-of-life experiences of four groups of chronic patients categorized according to whether they were inpatients of a state hospital or residents of a supervised community residence and whether their current length of stay had been less than or greater than six months. Regardless of length of stay, the community residents perceived their living conditions more favorably, had more financial resources, and were less likely to have been assaulted in the past year than the inpatients. The study illuminates the problematic living conditions of state hospitals and the benefits of appropriately designed community-based residences for the chronic mentally ill.     

A comprehensive review of palliative care in patients with cancer

Abstract

One of the most challenging roles for the psychiatrist is to help guide terminally ill patients physically, psychologically and spiritually through the dying process. Patients with advanced cancer, and other life-threatening medical illnesses are at increased risk for developing major psychiatric complications and have an enormous burden of both physical as well as psychological symptoms. In fact, surveys suggest that psychological symptoms such as depression, anxiety, and hopelessness are as frequent, if not more so, than pain and other physical symptoms in palliative care settings. Psychiatrists have a unique role and opportunity to offer competent and compassionate palliative care to those with life-threatening illness. In this article we provide a comprehensive review of basic concepts and definitions of palliative care and the experience of dying, and the role of the psychiatrist in palliative care including assessment and management of common psychiatric disorders in the terminally ill, with an emphasis on suicide and desire for hastened death. Psychotherapies developed for use in palliative care settings, and management of grief and bereavement are also reviewed.     

End-of-life care: a survey of US neurologists' attitudes, behavior, and knowledge.

OBJECTIVE: The American Academy of Neurology (AAN) surveyed the attitudes, behavior, and knowledge of its members regarding care at the end of life. Three groups of AAN members were surveyed: neuro-oncologists, ALS specialists, and a representative sample of US neurologists. METHODS: The survey presented two clinical scenarios involving end-of-life care. Neurologists were asked a series of questions to assess their knowledge of existing medical, ethical, and legal guidelines; their willingness to participate in physician-assisted suicide (PAS) or carry out voluntary euthanasia (VE); and their general attitudes regarding end-of-life care. RESULTS: Neurologists support a patient's right to refuse life-sustaining treatment, but many believe that they are killing their patients in supporting such refusals. Thirty-seven percent think it is illegal to administer analgesics in doses that risk respiratory depression to the point of death. Forty percent believe they should obtain legal counsel when considering stopping life-sustaining treatment. One half believe that PAS should be made explicitly legal by statute for terminally ill patients. Under current law, 13% would participate in PAS and 4% would carry out VE; if those procedures were legalized, 44% would participate in PAS and 28% in VE. Approximately one third believe that physicians have the same ethical duty to honor a terminally ill patient's request for PAS as they do to honor a such a patient's refusal of life-sustaining therapy. CONCLUSIONS: There is a gap between established medical, legal, and ethical guidelines for the care of dying patients and the beliefs and practices of many neurologists, suggesting a need for graduate and postgraduate education programs in the principles and practices of palliative care medicine. Many neurologists would participate in PAS and carry out VE if legalized.     

Delirium in the intensive care unit

Delirium is a common manifestation of acute brain dysfunction in critically ill patients with prevalence as high as 75%. In the last years there has been a progressive increase of publications regarding intensive care (ICU) delirium, acknowledging its importance. The occurrence of delirium in ICU is related to more adverse outcomes including self-extubation and removal of catheters, prolonged hospitalization, increased costs, higher mortality, and potentially, long-term cognitive impairment. The pathophysiology explaining the processes subtending the development of delirium is still elusive, though several theories have been discussed. It is known that different risk factors are associated with delirium in the ICU. Patients in ICU frequently receive medications to treat pain and to ensure sedation, but an association between these drugs and delirium has been shown. Therefore, this pharmacological exposure should be modified to reduce the risk factors. Giving the multifactorial genesis of delirium, multicomponent interventions to prevent delirium developed in non-ICU settings can be adapted to critically ill patients with the purpose of reducing the incidence. When delirium is diagnosed the use of typical and atypical antipsychotics may be effective for its treatment. Future studies should evaluate target interventions to prevent delirium in the ICU.     

Training residents to care for the mentally ill

Recent changes in Royal College training requirements have highlighted the need for residency programs to be able to offer challenging and worthwhile experiences to their trainees in caring for the chronically mentally ill. This training should bring them into contact with patients at each stage of their illness and recovery and expose them to the different settings in which treatment or management takes place. Postgraduate programs face many problems in organizing this teaching that arise from the nature and course of long-term psychiatric illnesses, the organization of residency training programs, attitudes and preconceptions of residents and teachers and competing time demands. The authors review these problems, identify specific goals for the training and suggest strategies for achieving these goals. Expectations of postgraduate programs, clinical placements, supervisors and residents themselves are outlined.     

A study on the standard of documentation of lumbar puncture in neurology department of a major Irish Teaching Hospital in Ireland

Objective:

Poor documentation following lumbar puncture (LP) had always been a matter of concern. This study aimed to investigate the documentation pattern of neurology house officers, registrars (Regs), and specialist Regs following LP in a major teaching hospital.

Materials and Methods:

Total hundred patient records were examined in the light of a carefully designed proforma containing 15 important indicators of good-quality LP documentation.

Result:

Mean number of indicators overall documented by doctors was found to be 6.24 ± 3.0037. The mean number of indicators recorded by house officers was 5.11 ± 3.01 and Regs was 7.56 ± 3.28. A total of 33% LPs were performed without a documented consent. Only 36% performers documented the type and size of needle they used during the procedure. Only 46% documents revealed the strength and name of the local anesthetic used. Statistically significant difference between senior house officers and Regs in terms of numbers of indicators documented was noted.

Conclusion:

The documentation standard among neurology junior doctors remained poor.Key Words: Consent, documentation, knowledge, lumbar, neurology, puncture     

What do police officers really want from the mental health system?

A sample of 309 police officers in Cincinnati and Hamilton County, Ohio, were interviewed about their contacts with mentally ill individuals and about their need for various kinds of information and assistance from the mental health system. During a one-month period, almost 60 percent of the officers had responded to at least one call involving a presumably mentally ill person, and 42 percent had responded to more than one such call. Twenty-two percent had dealt with a presumably mentally ill person who was also mentally retarded. Police officers indicated that they most needed access to information about an individual's past history of violence or suicide attempts, and quick on-site assistance by mental health professionals in assessing suicidal or hostile mentally ill persons.     

Social networks of residents in supportive housing

One goal of supportive housing is to enlarge and improve the functioning of the social support networks of residents. The networks of a convenience sample of 42 residents were assessed using scales developed by Barrera. The size of the networks (11.5) was no larger than that reported for similar clients living in other types of community settings but the composition differed. Staff and co-residents appear to partially replace rather than add to family and friends. This is of concern because friends are uniquely important determinants of satisfaction. An association between perceived need for support and network size was also found. These findings suggest some positive influences but also raise questions about unintended negative consequences of living in artificially constructed social environments.When this project was undertaken, Dr. Goering, Janet Durbin, Bill Lancee and Taras Babiak were all members of the Social and Community Psychiatry Section, Clarke Institute. Robert Foster was Executive Director of Regeneration House, Inc., where Susan Boyles is Assistant Executive Director.     

Medicalizing meaning: demoralization syndrome and the desire to die

OBJECTIVE: To critically analyse the proposed new psychiatric condition, demoralization syndrome, and the implications drawn by its proponents for the clinical-ethical status of requests by terminally ill patients for assistance to die. METHOD: The diagnostic features of demoralization syndrome, a proposed new psychiatric disorder, recognizable particularly in palliative care settings, are summarized. The consequences of proposed therapeutic interventions are described, one of which is relief of the desperation which motivates some demoralized patients to consider ending their lives and to seek assistance in dying. The connections between the proposed condition and the desire to die are analysed in the context of the continuing tensions surrounding the ontological status and sociopolitical implications of psychiatric categories and the pervasive medicalization of modern life. RESULTS: The analysis suggests that by medicalizing existential cognitions at the end of life, the proposed diagnostic category also normalizes a particular moral view concerning assistance in dying. CONCLUSIONS: While further research into the issues described in this provisional syndrome may benefit some patients, the categorization of demoralization as a medical diagnosis is a questionable extension of psychiatry's influence, which could serve particular social, political and cultural views concerning the end of life.     

The recognition of psychiatric morbidity on a medical oncology ward

The Generalised Health Questionnaire and Standardised Psychiatric Interview were used to determine psychiatric morbidity among 126 patients consecutively admitted to a medical oncology unit. Senior house officers and nurses also rated anxiety and depression. 36 (29%) patients were psychiatrically ill and affective disorders (29, 23%) predominated. Psychiatric morbidity was associated with feeling moderately or severely physically ill, and previous psychiatric illness, but not with awareness of having cancer or lack of a confiding tie. The General Health Questionnaire identified 79% of affective disorders at the cost of a 34% false positive rate. Doctors and nurses recognised only 49% of the depressed group; more of those with morbid anxiety (79%) were identified but only because they assumed most patients were anxious. Training in interviewing skills could substantially improve the identification and referral rates of patients with psychiatric morbidity.     

Should physician training centers offer formal psychiatric assistance to house officers? A report on the major findings of a prototype program

The literature suggests that the emotional needs of interns, residents, and fellows have received inadequate attention. Comprehensive psychiatric services are provided by a model program at UCLA. During the 1981-1983 academic years, 89 house officers were seen. Between 16% and 19% of certain groups sought help each year; depression was the most frequent diagnosis (63%, N = 56), followed by anxiety disorders (24%, N = 21). Over two-thirds of the evaluated residents entered free or low-fee treatment, and these therapies were generally considered quite beneficial. This report reemphasizes the desirability of providing carefully structured, confidential psychiatric assistance to house staff and documents medical trainees' acceptance and use of such programs.