1- 60 yrs old lady with recurrent depression and psychotic features [hears voices] did not respond fully to anti psychotic was told that EL T is the best ttt for her. ans. The most obvious reasons for giving EL T is that she agreed to the ttt and it is necessary for her. There are doubts that the consent is valid, it is unclear if it fits the emergency exception to the rule of obtaining consent. -3 elements of consent: each must be notified - disclosure: physician should inform the patient about proposed tests & ttt. -voluntaries: pt. makes the decision of ttt without undue external coercion -capacity: pt. must be capable to understand the consequences of a decision or lack of decision.
Consent in psychiatry includes the right to start ECT ttt. Consent in emergency: To save patient’s life, preserve their health and a delay jeopardizes life or death and pt. cannot make decisions. if a substitute decision maker can be contacted, emergency consent is not used.
2-Diabetic foot patient’s case no 3, the psychiatrist has been asked to assess his capacity to give consent. • The patient has the right to refuse surgery provided he is competent.
Capacity is ability to understand information and appreciate consequences of a decision or lack of decision. Severe depression can affect cognition, ACE [Aid to capacity evolution] assist clinicians decide capacity. To be capable; a- understand situation b-understand risk and consequences of proposed ttt. c-understand risk and consequences of refusing ttt. d- the choice to be made without coercion Psychiatrist usually decides capacity of patient.
3- Substitute decision making Patients have the right to refuse ttt. based on their autonomy but incompetent patients cannot exercise this right - substitute decision making can do on his or her behalf, decision making should be someone appointed by the patient while he is competent or the patient’s nearest relative. -If the disability is permanent and there is disagreement about care --> appointed guardian by court.
4- Psychotherapist treats a pt. who wants to close his file. Contact third party [family, friends, police officer, social worker] Involuntary hospitalization, to whom disclosure should be made. ans. in case of threat involving body harm, the victim and the police should be notified without delay. confidentiality.
5- Rationing decisions or allocation are considered for greater benefit or greater need. -resource allocation.
6- When can you hospitalize a patient involuntaryl -when he is a source of harm for others or himself. -In North America, the police power is the preliminary justification for involuntary hospitalization. -Hospitalization without ttt does not seem to be in the patient’s best interest but necessary to protect the public [patient may be hospitalized but refuse psychiatric ttt.] Involuntary hospitalization.
7 - Transference and counter transference A female 29 yrs , pianist ttt of drug abuse, alcoholic, and history of suicidal attempts treated by Dr Jones every 2 weeks for 6 months, she is demanding more visits to Dr Jones, called him twice to tell him she got overdose of alcohol and drugs, he called the ambulance for her, she does not take treatment regularly, her father committed suicide when she was 12 yrs and her mother is alcoholic. She has bad reputation in work being moody.
She admits taking drugs to overdose to attract Dr Jones’ attention to give her more frequent sessions. Dr Jones referred her to the psychiatrist, he starts to feel uncomfortable treating her and she wants the psychiatrist’s opinion. ans. Borderline personality. The psychiatrist would recommend to Dr Jones; refer the patient, hospitalize if necessary. The ethical principles here are beneficence and non maleficience. Legal aspects here: Therapists working with borderline personality are often sued for suicide and sexual misconduct. Both the proper maintenance of treatment boundaries and management of patient’s transference are crucial to avoid ethical & legal pitfalls.
8- A female 31 yrs old teacher brought to the emergency by a friend who is concerned about her depression and withdrawn condition. She had therapeutic abortion 6 months ago. Her boyfriend left her when he knew about her preg. and she did not want to have a baby without a father. She lost interest in life lost weight in the last 2 months, sometimes leaves her work crying, she collects aspirin and tylenol to kill herself but lacks energy to do so, her uncle committed suicide. ans. there is risk that she may commit suicide but this is not certain she is presumed to be capable but suicidal ideation raises doubt about competence, you could offer her short hospitalization to assess capacity, risk of suicide and the success of treatment. Involuntary admission should be considered if she refuses.
9- Sexual impropriety A woman who has an affair with her psychiatrist after 3 years of this affair he referred her on basis of her suffering from psychotic symptoms and he cannot treat her any more. And she is bashful and does not want to report her story. ans. you have to report the case as you heard it to the appropriate licensing authority because if the allegation was true he may be harmful to others but you do not release her name without her permission. You are neither an investigator nor a judge and he is innocent till proved guilty. You encounter no legal liability to report but if you do not report, you may be reported by a patient or another professional. -A medical doctor should not initiate any sexual advance to a patient nor respond sexually to any sexual advance from the patient.
10-research ethics; You are on a study on a new antipsychotic drug and you need a pt to try it on her as she is not regular on her drug intake but her WBe is 45x(10)9 and it should be 3.5x(10)9 and she wants to try the new drug. ans. Violating research protocol leads to immediate distrust, you can use your patients in research provided that there is plan for research which is approved by ethics board [independent] and the patient gives you consent.
They may be given placebo versus a drug but they should never be put at a disadvantage by their participation in research and be assured to be given the best proven diagnostic and therapeutic method