When Patients and Providers Feel Helpless: A Commentary on "Palliative Care for Refractory Depressive Symptoms in a Female Veteran Geriatric Patient".

AbstractWhether providers should ever help patients die when they profoundly suffer from seemingly irreversible psychiatric illness is globally controversial. For example, in 2016, the American Psychiatric Association held that psychiatrists should never help bring about such patients' deaths, whereas in the Netherlands this intervention has been permitted for 30 years, and the number has increased from 2 in 2011 to 83 in 2017. This commentary asks when, if ever, providers should give up on seeking to treat these patients. Providers who have been exceptionally successful at reaching and helping these patients and some of the approaches they used are presented. These include particularly their helping these patients see meaning in their lives, using humor, and understanding them or at least trying to. I propose that establishing a felt connection may always remain possible and that this end may be a more important goal than any other.

Should Providers Ask Family Members What They Want When Establishing Surrogate Decision-Making?

AbstractIn this piece I discuss optimal approaches that providers may take when pursuing surrogate decision-making. A potential critical problem here is some providers' approach differing from that of others. To the extent that this occurs, the results may be arbitrary, and the harm from this may be profound since this may affect, of course, even whether some of these patients will live or die. One factor possibly resulting in these differences is the moral weight providers place on what family members want when these outcomes differ from what they think patients would want. Providers now most commonly place greatest moral weight on following what patients would want to maximally respect their autonomy, but this view may clash with the view of others who see autonomy as more relational and thus based on prior and present social relations with others. Giving family members' wants more moral weight is a radical departure from what providers do now and may increase these differences. I discuss here the rationales for and against these competing choices.

How Should Therapists Treat Patients who are so Altruistic They Regularly Harm Themselves for the Sake of Others?

Mental health providers sometimes encounter patients who are exceptionally altruistic toward others and, at the same time, are willing to ignore their own needs and even significantly harm themselves to best achieve these ends for others. Traditionally, therapists have seen it to be their role to discern patients' negative symptoms, then seek to reduce them. This article reviews gains based on positive psychology that highlight the importance of therapists giving priority to supporting patients' strengths, particularly the sources of meaning they have in their lives. As is consistent with this view, it is suggested that therapists working with this group of self-harming, altruistic patients not only support their altruism, but particularly consider and remain cautious as to whether or not they should explore unconscious factors with the patient that might fuel their altruism. It is suggested that the discovery of such factors might be harmful because it could risk decreasing the degree to which these patients continue to show and personally value their altruism, thus potentially decreasing the meaning they derive from their altruism.

Should Providers Advocate for Their Patients?

AbstractThis piece discusses several ways in which providers may advocate for patients and their families that go beyond what providers usually do to help their patients. A much more expanded view of advocacy is suggested. Real cases illustrating all interventions suggested are presented, and each is paradigmatic of numerous others. Categories of possible options suggested for expanded advocacy include (1) providers enhancing patients' outcomes when standard treatments have failed, (2) providers taking measures outside those they usually take to benefit patients to a greater extent, and (3) providers sacrificing their own needs more than they customarily do to help their patients still further. The suggested interventions are practical and can be implemented immediately. Taken together, the interventions proposed are also aspirational.

Psychotherapeutic approaches: hopefully, globally effective.

Many patients have lasting disorders due, for example, to excessive and chronic childhood stress. For these patients, certain psychotherapeutic approaches may be maximally effective, and this may be universally the case. This piece is intended to give providers optimal tools for reaching and helping these patients who, otherwise, may remain among those worst off. These interventions should enhance patients' trust, the quintessential precondition for enabling these patients to change. Specific interventions discussed include anticipating ambiguity and clarifying this before ambiguity occurs, therapists indicating that they will support patients' and families' wants over their own views, feeling and disclosing their emotions, validating patients' anger, laughing, going beyond usual limits, explaining why, asking before doing, discussing religion and ethics, and informing whenever this could be beneficial.

New Ways to Help Patients Worst Off.

AbstractThis introduction to The Journal of Clinical Ethics highlights and expands four articles within this issue that propose somewhat new and radical innovations to help and further the interests of patients and families worst off. One article urges us to enable historically marginalized groups to participate more than they have in research; a second urges us to allocate limited resources that can be divided, such as vaccines and even ventilators, in a different way; a third urges us to help families find greater meaning when their loved ones are dying; and a fourth urges us to treat patients who illegally use drugs as caringly as is possible, though there may be limits to what providers can do. This piece also addresses the importance of providers bonding with patients, recognizing that some providers may be better at eliciting patients' trust than others, and thus the importance of connecting these patients with these providers since this may be the sole way these patients can optimally respond and do well. Finally, providers taking time away from their patients to oppose and reduce social stigma is considered.

Ethical considerations for psychedelic-assisted therapy in military clinical settings.

Psychedelic treatments, particularly 3,4-methylenedioxymethamphetamine (MDMA)-assisted and psilocybin-assisted therapies, have recently seen renewed interest in their clinical potential to treat various mental health conditions. Clinical trials for both MDMA-assisted and psilocybin-assisted therapies have shown to be highly efficacious for post-traumatic stress disorder and major depression. Recent research trials for psychedelic-assisted therapies (PAT) have demonstrated that although they are resource-intensive, their effects are rapid-acting, durable and cost-effective. These results have generated enthusiasm among researchers seeking to investigate psychedelic therapies in active-duty service members of the US military, particularly those with treatment refractory mental health conditions. At the same time, psychedelics remain in early stages of clinical investigation, have not yet achieved regulatory approval for general clinical use and may confer unique psychological and neurobiological effects that could raise novel ethical considerations when treating active-duty service members. Should psychedelics achieve regulatory approval, military relevant considerations may include issues of access to these treatments, appropriate procedures for informed consent, confidentiality standards, and possible unanticipated mental health risks and other psychological sequelae. A service member's deployability, as well as their ability to return to full military duty following PAT, may also be of unique concern. The authors argue that MDMA-assisted therapy currently represents a promising treatment that should be more rapidly investigated as a clinical therapy for service members while still taking a measured approach that accounts for the many military-specific uncertainties that remain.

When Should Providers Defer versus Impose Their Views?

AbstractThis piece discusses perhaps the most agonizing ethical decision ethics consultants and other providers encounter. This is the extent to which providers should defer decisions to patients or to their proxy decision makers as opposed to imposing their own views as to what they think is ethically right. It discusses the most difficult issues these providers may encounter, especially when they wish to depart from authoritative bodies' standards or guidelines, and it presents initial steps providers may take to help patients and their families work together to resolve these dilemmas more harmoniously. It highlights how providers may inadvertently impose flawed biases on patients and families. Finally, it discusses how providers should take initiative with both parties to offer to help appeal when these avenues already exist and seek to establish the appellate procedures when they are absent.

White Noise and Questions Regarding Death Anxiety, Forgiveness, and Patient Self-disclosure.

This commentary examines three critical therapeutic questions that arise for all patients, particularly for patients with psychiatric illness. These questions involve fearing death, forgiving oneself for past acts, and disclosing medical and psychiatric conditions to others. These questions, which can be critical to providing optimal medical care in some contexts, are prompted by the movie White Noise, as it might provoke questions regarding death and self-disclosure in patients. Specific responses that might be helpful to patients are offered.

Patients with Invisible Pain: How Might We See This Pain and Help These Patients More?

AbstractIn this piece I discuss two ways in which providers may become able to treat patients better. The first is for them to encourage all medical parties, including medical students, to always speak up. The second is to take initiatives to learn of pain that patients feel but neither show nor spontaneously report. They may refer to this pain as invisible pain, often bitterly, in that others not seeing their pain judge them wrongly and harshly. Providers, once seeing this pain, are encouraged to then take additional measures to try to alleviate it. Clinical examples provided to illustrate the range of treatments providers may add are post-traumatic stress disorders, problems involving substance use, and hoarding disorders. Similar concerns regarding people who are deaf and hard of hearing are also addressed.

When, If Ever, Should Care Providers Neither Contact Families of Suicidal Patients to Gain More Information Nor Hospitalize Patients?

AbstractIn this piece I discuss when care providers should not contact suicidal patients' families to get collateral information from them or hospitalize patients over their objections. I suggest that when these patients are chronically suicidal, overriding these wants may be best in the short run but increase their net risk in the longer run. I also discuss in this regard how contacted families may become overprotective and how hospitalization can be traumatic. I present an alternative approach that can increase these patients' safety over the longer run and relate three practical approaches care providers may find useful: explaining their decisions to patients, monitoring their own fear, and instilling hope.

Questions Care Providers Should Ask When They Have Ethical Discretion.

AbstractSince some care providers give colleagues' interests priority over patients' and families', they are at risk of imposing their bias on patients without knowing this. In this piece I discuss how the risk increases when care providers have greater discretion and how they can best avoid this risk. I discuss identifying these situations, assessing them, and then, based on what they have concluded, intervening and use their having inadequate resources, their seeing what patients want as futile, and their making decisions regarding surrogate decision makers as paradigmatic examples. As "remedies," I suggest that care providers share with patients their rationales, validate adaptive aspects of difficult behaviors, self-disclose, and sometimes even go beyond their usual clinical practices.

Endoscopic Approaches to the Paramedian Skull Base: An Anatomic Comparison of Contralateral Endonasal and Transmaxillary Strategies.

BACKGROUND: The expanded endoscopic endonasal approach (EEA) is limited laterally by the internal carotid artery (ICA). The EEA to the paramedian skull base often requires complex maneuvers such as dissection of the Eustachian tube (ET) and foramen lacerum (FL), and ICA manipulation. An endoscopic contralateral transmaxillary approach (CTMA) has the potential to provide adequate exposure of the paramedian skull base while bypassing manipulation of the aforementioned anatomic structures. OBJECTIVE: To quantify and compare the surgical nuances of a CTMA and a contralateral EEA when approaching the paramedian skull base in cadaveric specimens. METHODS: Five adult cadaveric heads were dissected bilaterally (10 sides) using a contralateral EEA and a CTMA to expose targets of interest at the paramedian skull base. For each target in both approaches, the surgical freedom, angle of attack, the corridor's "perspective angle," and "turning angle" to circumvent the ICA, ET, and FL were obtained. RESULTS: The CTMA achieved superior surgical freedom at all targets ( P < .05) except at the root entry point of cranial nerve XII. The CTMA provided superior vertical and horizontal angles of " attack " to the majority of targets of interest. Except when approaching the root entry point of cranial nerve XII, the CTMA " turning angle " around the ICA, ET, and FL were wider with CTMA for all targets. CONCLUSION: A CTMA complements the EEA to access the paramedian skull base. A CTMA may limit the need for complex maneuvers such as ICA mobilization and dissection of the ET and FL when approaching the paramedian skull base.

The "Crista Ovale": A Reliable Anatomical Landmark in Transorbital Endoscopic Approaches to the Middle Cranial Fossa.

BACKGROUND: Transorbital endoscopic approaches (TOEAs) have emerged as adjunct and alternatives for accessing the middle cranial fossa (MCF). Nuances of the skull base anatomy from a ventral transorbital endoscopic viewpoint remain to be fully described. OBJECTIVE: To assess the anatomy of the "crista ovale" (COv), described transcranially as the midsubtemporal ridge (MSR), from a ventral transorbital perspective and evaluate its role as a landmark in TOEA to the MCF. METHODS: Lateral TOEAs to the MCF were performed in 20 adult cadaveric heads (40 sides). The presence of the COv/MSR was evaluated under endoscopic visualization. Anatomic relationships between COv/MSR and surrounding structures were assessed. The presence of COv/MSR was also examined in 30 cadaveric head computed tomography (CT) scans (60 sides). RESULTS: The COv/MSR was identified in 98% (39/40) of sides at the MCF, as 1 of 4 major configurations. The COv/MSR was found anterolateral to the foramen ovale and foramen spinosum (mean distance: 9.2 ± SD 2.4 mm and 12.3 ± SD 2.6 mm, respectively) directly anterior or anteromedial to the petrous apex (mean distance: 26.2 ± SD 2.6 mm) and at a mean 47.6 ± SD 4.7 mm from the approach's surgical portal. It was recognized in 95% (57/60) of CT scans. CONCLUSION: The COv/MSR can be readily identified during TOEA to the MCF and on CT. It serves as a reliable landmark to localize the foramen ovale, foramen spinosum, and petrous apex. Further studies may confirm its surgical significance in transorbital endoscopic procedures.

Should Ethics Consultants Make their Findings Transparent? How Important Is "Intimacy" between Patients and Careproviders?

A recently enacted law permits patients to see their electronic medical record (EMR) immediately after their careprovider writes in it. In this article I discuss a proposal that authors make in this issue of The Journal of Clinical Ethics, that ethics consultants (ECs) keep their notes in a separate section of the EMR that patients cannot access when their ethics notes may be troubling to patients, to avoid unduly harming them. I discuss this concern and three more widely applicable clinical goals: to help patients feel safe; to gain patients' trust; and to provide hope to patients, when possible. These goals apply to careproviders and ECs who seek to help patients and families resolve ethical conflicts. I explain why these goals are singularly important and how careproviders may pursue them, using as an example informing patients about temporal framing to help them find hope.

When Should Careproviders Deviate from Consensus?

Consensus documents may be extremely helpful. They may, however, also do harm. They may, for example, suggest interventions that are less than optimal, especially when they apply to patients whose situations are at the "outer margins" of their applicability. Yet, even in these instances, clinicians and ethics consultants may still feel pressure to comply with a guideline. Then, we may not do what we think is best for our particular patient because we fear departing from a guideline. In this article I discuss the risks of departing from guidelines and suggest what we can do to overcome those possible risks. I suggest that while guidelines may help, we should continue to put, above all else, tailoring our interventions to our patients' individual needs and wants. With our patients, together, we should decide what to do, notwithstanding what the most applicable guidelines propose.

Assessing Patients Who Seek Help Ending Their Lives.

As a result of end-of-life movements in a number of states, psychiatrists may be drawn into the capacity assessment of patients requesting assistance to end their lives. Such assessments cannot follow the mere technicalities of common clinical interviews, not simply because of the finality of the choice, but also because of the limitations of common cognitive assessments. The Committee on Professionalism and Ethics of the Group for the Advancement of Psychiatry consequently proposes an interview for such purposes that explores a patient's emotional capacity through a narrative inquiry about the patient's life, past coping, and reversible emotional states. It is a neutral approach that seeks to understand the patient rather than judge the appropriateness of an end-of-life request.

Seeing the Invisible.

This article focuses on three different ways that we may demean people by seeing them as less than they are, and describes ways we may best avoid doing this. More specifically, I explain how we may not see the physical and emotional issues that plague patients and others. This may be because they choose not to disclose their difficulties to us. We may also err when we see only one aspect of who and how others are. These challenges pose ethical quandaries that involve equity, improved communication with patients, and subjecting ethical principles to empirical study before we adopt them. I explore the means to do these.