Obtaining informed consent of patients at risk of neuroleptic malignant syndrome.

Thirty psychiatrists completed a mailed questionnaire about their attitudes toward obtaining informed consent and about the frequency with which they obtained it from patients taking neuroleptic medications who were at risk of tardive dyskinesia, a relatively common but nonfatal side effect, and neuroleptic malignant syndrome (NMS), an uncommon but potentially fatal side effect. Only one psychiatrist reported always or almost always informing patients about the risk of NMS. Psychiatrists were significantly less likely to inform patients about the risk of NMS than the risk of tardive dyskinesia. Psychiatrists may not be aware of the risk of NMS and may not know what information to provide to patients.

Informed consent for antipsychotic medication.

OBJECTIVE: To determine family physicians' attitudes and practices regarding documentation of informed consent for antipsychotic medication. DESIGN: Pilot cross-sectional study. SETTING: Teaching and non-teaching hospitals in Toronto, Ont. PARTICIPANTS: Thirty family physicians were selected in equal numbers from teaching and non-teaching hospitals with no more than five physicians from a given hospital. Participants were treating at least 10 patients with antipsychotic medication. Participants' mean age was 44.3 years; 83% were men. MAIN OUTCOME MEASURES: Documentation of consent and of disclosure of consent for antipsychotic medication in patients' charts. RESULTS: Documentation was found in only 13% of charts. Whether it was there or not did not correlate with information disclosed, score on an attitude scale, or demographics. Physicians who found documentation time-consuming were less likely to document. Most physicians disclosed reasons for antipsychotic medication, but less than half described tardive dyskinesia, a potentially irreversible movement disorder that affects about 25% of patients on long-term treatment. CONCLUSIONS: The low rate of documentation observed in this sample was consistent with reports of similar samples and might indicate that family physicians are unaware of recommendations for documentation or simply do not have time to keep abreast of current recommendations. Many physicians thought signed consent forms unnecessary for psychotic patients, and even more believed seeking consent for antipsychotic medications would increase patient anxiety.

Psychiatrists' documentation of informed consent.

OBJECTIVE: The present study was undertaken to determine current attitudes and behaviour toward informed consent for antipsychotic medication and documentation of the informed consent process in patient charts. METHOD: Thirty psychiatrists treating a minimum of 10 patients on antipsychotic medication were selected from teaching and nonteaching hospitals. Clinicians completed questionnaires on their behaviour and attitudes regarding documentation of informed consent and antipsychotic medication. Physicians' charts were reviewed to ascertain documentation. RESULTS: Psychiatrists reported sometimes documenting the informed consent process. The chart review revealed that, on average, each psychiatrist had documentation in 23% of charts. Physicians who either were affiliated with a teaching hospital or spent more time reading medical journals were more likely to document the informed consent process. CONCLUSIONS: Physicians who use antipsychotic medication as a treatment in their practice are not routinely documenting the informed consent process in patient records. Physicians should pay more attention to this aspect of record keeping because it is their only record of the consent process.

Bioethics for clinicians: 8. Confidentiality.

Physicians are obliged to keep information about their patients secret. The understanding that the physician will not disclose private information about the patient provides a foundation for trust in the therapeutic relationship. Respect for confidentiality is firmly established in codes of ethics and in law. It is sometimes necessary, however, for physicians to breach confidentiality. Physicians should familiarize themselves with legislation in their own province governing the disclosure of certain kinds of information without the patient's authorization. Even when no specific legislation applies, the duty to warn sometimes overrides the duty to respect confidentiality. The physician should disclose only that information necessary to prevent harm, and should reveal this information only to those who need to know it in order to avert harm. Whenever possible any breach of confidentiality should be discussed with the patient beforehand.

Informed consent and tardive dyskinesia. Long-term follow-up.

Informed consent allows patients to make treatment decisions based on the best possible information. The current study examines the long-term impact of the informed consent process on schizophrenic patients. Patients were administered a baseline questionnaire and were given an information form, which was read aloud to them by the investigator. Patients were re-administered the questionnaire at 4 weeks and were randomly assigned to no review (single-session group) or a review of the information (educational review group). All patients were administered the questionnaire at 2-year follow-up. Both the single session and the educational review process significantly increase the schizophrenic patient's knowledge about the benefits and risks of neuroleptic medication. No previous study has examined the impact of informed consent for antipsychotic medication at 2-year follow-up.

Suicide: the interaction of clinical and ethical issues.

Although bioethical principles such as beneficence, nonmaleficence, and autonomy increasingly guide clinical decision making, in good clinical practice none of these principles is absolute. The authors describe how clinical and ethical issues interact in prioritizing principles in the treatment of suicidal patients. For the acutely suicidal patient, beneficence must be given primacy, as it should for the chronically suicidal patient who is unable to control self-destructive impulses. However, some chronically suicidal patients may be capable of resisting these impulses, and in such situations, respecting patients' autonomy facilitates clinical work and prevents the therapist from being drawn into a role that encourages regression. The successful management of the suicidal patient illustrates the need for dynamic, rather than rigid, application of ethical principles.

Written advance directives refusing blood transfusion: ethical and legal considerations.

A patient's automony and right to determine his or her treatment is widely recognized in current ethical theory and medical practice. However, conflicts between the desire to respect a competent patient's religious conviction not to be violated and society's interest in preserving life do arise. This paper examines two cases involving Jehovah's Witnesses who signed cards refusing blood transfusions and who were subsequently transfused. In the Canadian case, the physician was found liable for battery. In the American case, the courts upheld the appointment of a guardian who authorized the transfusion. In the emergency situation, if there is a reasonable doubt about the validity of a treatment refusal, the presumption must be to render life-saving treatment. The author believes, however, that a written advance directive could be developed that respects he religious convictions of Jehovah's Witnesses and the ethical and legal responsibilities of physicians.

Placebo pain medication. Ethical and practical considerations.

The placebo effect on pain is a complex phenomenon. The unconsented use of placebo pain medication, however, raises concerns given the risks both to patient trust and to the medical profession's reputation in condoning deception, the inherent distastefulness of deception, the misuse of placebos that occurs, and the fact that the information obtained is often of negligible value. The main justification given for using placebos is based on the assumption that they are effective and beneficial to patients. We argue that placebo pain medication should be prescribed to patients only with their informed consent in scientifically rigorous single-patient studies. The results of such trials would constitute a particularly useful way of resolving uncertainty in the treatment of patients whose pain is poorly controlled.

Ethical considerations in living organ donation and a new approach. An Advance-Directive Organ Registry.

Living organ donation should be recognized as an ethical compromise to the principle of nonmaleficence (doing no harm), given the risks healthy donors are allowed to assume. Living organ donation should be reserved for situations in which there is no acceptable alternative. Increasing the availability of cadaveric organs is most desirable, since it would decrease (although probably not eliminate) the need for living organ transplantation and would provide organs (ie, hearts) that could not otherwise be obtained. We propose the development of an incentive-based Advance-Directive Organ Registry, in which all adults are encouraged to register their advance directive regarding organ donations. Those individuals agreeing to permit usable organs to be taken at the time of death would receive priority for organs generated by the program, should a transplant become necessary when there is a shortage of organs. The proposed Advance-Directive Organ Registry is firmly founded on the principles of autonomy, beneficence, and justice.

HIV transmission: ethical and legal considerations in psychotherapy.

Psychiatrists, particularly psychotherapists, have access to the most intimate details of patients' lives. As a result, psychiatrists may face a number of ethical dilemmas, particularly when the issue of potential human immunovirus (HIV) transmission is involved. This paper examines the principle and the limits of confidentiality, and outlines various ways to resolve situations in which there is a conflict between the risk of HIV being transmitted to the unsuspecting public and the principle of confidentiality. Psychiatrists should not assume that patients engaged in high risk behaviour that may be self-destructive fully understand the risks involved. An educational approach may be warranted with these patients, even though such an approach would not be consistent with non directive therapy.

The lifetime prevalence of psychopathology in men with multigenerational family histories of alcoholism.

This paper reports the results of a pilot study of the lifetime prevalence of psychiatric disorders in a group of nonalcoholic men with multigenerational family histories of alcoholism (high-risk) in comparison with that of a control group (nonalcoholic men without multigenerational family histories of alcoholism). Diagnoses were given following the structured interview format of the Schedule for Affective Disorders and Schizophrenia, using the Research Diagnostic Criteria. The prevalence of psychopathology in the probands' first- and second-degree relatives was also determined using the Family History Research Diagnostic Criteria. The results showed a higher lifetime prevalence of psychopathology for the high-risk men compared with control subjects, with the diagnoses of major affective disorder and anxiety disorder predominating. In addition, the data obtained from first- and second-degree relatives indicated a significantly higher prevalence of nonalcoholic diagnoses in the high-risk families (depression in particular), suggesting that alcoholism and depression may be cosegregating in these families. The lifetime prevalence of these disorders is similar to that reported in chronic alcoholics.

Death of the analyst.

This paper assesses the impact that the death of two training analysts had on their analysands. The dependent variable, which is length of analytic training, was chosen because it is objective, easily measured and should reflect the disruption due to an analyst's death. Patients of the deceased analysts had a significantly increased length of training (Fisher's exact probability, p less than .02). This work reviews a number of relevant methodological issues and attempts to show how one can examine observable phenomena empirically. It is hoped that clinicians will begin to address how their psychotherapeutic work could be assessed using scientific methodology.

Informed consent and tardive dyskinesia.

To determine whether a formalized informing process transmitted knowledge concerning the risks and benefits of neuroleptic medication, particularly the risk of tardive dyskinesia, to stable schizophrenic outpatients, the authors administered a multiple-choice questionnaire to 21 patients who were read a standardized information form and 27 patients who were not. The mean scores for the informed patients were significantly higher, and the differences between the two groups remained significant at 6-month follow-up. The information process had no adverse effects on frequency of psychiatric admission, noncompliance with medication, or the need for increased antipsychotic medication.