A combined ethics & psychiatric consultation.

A case presentation is used to illustrate how psychiatrists can contribute to clinical ethics. A 75-year-old man with end-stage COPD was admitted to the ICU. His condition deteriorated and he lost decision-making capacity without expressing his wishes about end-of-life care. Although he no longer needed care in the ICU his surrogate decision-maker objected to his being transferred. Seven months after the patient's admission an ethics consultation was carried out by a psychiatrist-ethicist. The following issues are discussed, elaborating on points previously made by the authors [1,2]: the absence of an advance directive, surrogate decision-making, the allocation of ICU beds, guidelines for discharge from the hospital, the lateness of the ethics consultation, and the interweaving of ethical questions with psychiatric factors. The psychiatrist-ethicist was ideally suited to address all these issues and to make a significant contribution to the care of the patient and his family.

Disentangling ethical and psychological issues--a guide for oncologists.

The rapid growth of bioethics has injected a new style of analysis into medicine. It requires philosophical rigor, yet is deeply embedded in human situations that frustrate abstract thinking and are laced with subjective factors. These interlaced ethical and psychological components can lead to conflicts and dilemmas. Doctors, as experts and decision-makers, play a key role, but will benefit from additional skills to disentangle these situations. This paper notes ways in which patients, families and caregivers are newly vulnerable and delineates how ethical dilemmas and psychological issues mold or frustrate decision-making. To help physicians manage such cases, a method of systematic analysis, the 'situational diagnosis', and a related hierarchy of interventions, is described and illustrated with case examples.

An annotated bibliography for ethics training in consultation-liaison psychiatry.

The expanding field of bioethics has created a need in psychiatry for rapid access to the complex bioethics literature. This is especially true in consultation-liaison work. An annotated bibliography was created by a task force of the Academy of Psychosomatic Medicine charged with exploring how psychiatrists function on bioethics committees. The bibliography is organized into headings that reflect how bioethical problems came to the attention of psychiatrists. Introductory references allow the reader an overview of the history of bioethics and a selection of useful textbooks. References are provided explaining how ethical principles are used. References are also organized by areas of medical work frequently visited by consultation-liaison psychiatrists.

Nicotine dependence and withdrawal in an oncology setting: a risk factor for psychiatric comorbidity and treatment non-adherence.

Highly nicotine dependent oncology patients are at high risk for psychiatric morbidity when they enter the medical care setting where smoking restrictions apply. Nicotine withdrawal symptoms exacerbate cancer-related distress as well as common physical side effects of cancer treatment. This case report illustrates the management of a patient whose ongoing treatment for bladder cancer was jeopardized as a result of nicotine dependence and withdrawal. Several associated complications are described, the most serious of which were his acute anxiety and non-adherence to medical recommendations. A short-term management approach that included anxiolytics and nicotine replacement was effectively used to reduce this patient's excessive anxiety and thus facilitate compliance with stressful treatments. The severity of complications that can result from untreated nicotine dependence and withdrawal underscores the importance of assessing and monitoring smoking status in every patient. Greater staff awareness of the clinical practice guidelines regarding the diagnosis and treatment of nicotine dependence will likely result in improved patient care and compliance.

Staff support groups for high-stress medical environments.

Recent changes in health care delivery have added new demands to the already stressful work of medical staff, which makes the benefits of staff support groups all the more cogent. The author describes a conceptual approach to such groups and analyzes the systems issues that need to be understood to penetrate a complex institution successfully. Staff stressors are outlined along with the staff's psychological responses. Specific goals for support groups are considered and the profound technical differences between psychotherapy and support groups are delineated. The developmental stages of staff groups and their associated themes are described in tandem with practical guidelines about starting, maintaining, and terminating such groups. Special requirements of leadership style and related countertransference issues are reviewed.

Making a situational diagnosis. Psychiatrists at the interface of psychiatry and ethics in the consultation-liaison setting.

Psychiatrists bring a unique understanding to clinical ethics, but psychiatrists need a precise awareness of the difference between exercising their clinical expertise and facilitating ethical decisionmaking. The author outlines a schema for recognizing and honoring that distinction and illustrates "pseudoethics," "pseudopsychiatry," and "psychiatry/ethics" consultations. The author describes how to make a "situational diagnosis" that includes patient/family issues, staff issues, joint issues, legal/regulatory issues, and ethical issues, thus enabling the psychiatrist to institute an appropriate "hierarchy of interventions": educational, psychological, and ethical. The literature on ethics education for psychiatric practitioners is reviewed and a program is suggested.

Doctors in limbo: the United States 'DNR' debate.

Cardiopulmonary resuscitation is unlike any other medical intervention in its emotional impact. Its original use in reversible conditions has been replaced by its expected use in irreversible ones. The history of this transformation and its psychological concommitants are reviewed. New York State is unusual in having a 'DNR' law where resuscitation is the default position unless actively refused by patient or surrogate. The paradoxical genesis of this law, and its complex effect on a tertiary care hospital are described. Attention is focused on the emotional stresses on medical staff, and the extensive teaching program mounted by the institution's ethics committee to enable a positive adaptation. The difficulties inherent in surrogate decision-making are also reviewed.

Compliance with New York State's do-not-resuscitate law at Memorial Sloan-Kettering Cancer Center. A review of patient deaths.

We reviewed the case records of 141 patients (134 with cancer and seven with acquired immunodeficiency syndrome) who died at Memorial Sloan-Kettering Cancer Center between July 11 and September 19, 1991. Do-not-resuscitate orders had been written on 115 (85.8%) of the patients with cancer and all of the patients with acquired immunodeficiency syndrome. The do-not-resuscitate orders appeared to be valid, in that evidence of informed consent was documented in all but two of the cases. Six additional patients who died had family consent not to resuscitate, although no do-not-resuscitate orders were written. Two other patients died unexpectedly. The remaining 11 patients all received aggressive attempts at resuscitation, which were felt to be medically appropriate in all but two cases. The interval between the do-not-resuscitate order and death was between zero and 60 days, with an average of 8.4 days and a median of 6 days; it exceeded 20 days in 14 cases. We attribute the high degree of compliance with the New York State do-not-resuscitate law observed in this study to an intensive program of consultation and education begun in 1987 by the Ethics Committee of Memorial Sloan-Kettering Cancer Center.

Characteristics of psychiatric consultations in a pediatric cancer center.

Data on psychiatric consultations with 58 pediatric cancer patients are summarized. Although most patients received DSM-III axis I diagnoses, adjustment disorder was diagnosed in 30 cases (52%). The patients with primarily depressive features were significantly older than those with anxious features.