[Ethics of assertive outreach: a case study]. / Ethiek van de bemoeizorg: een casusbespreking.

BACKGROUND: Caregivers need an ethical compass to find a way in assertive outreach. AIM: To develop an ethical framework of gradual care. METHOD: Using a case study, the ethical framework of gradual care is presented and applied. RESULTS: The starting point is a relational view of the human being. Consequently, a first condition is that caregivers build up a relationship of trust with the client. At the same time, they assess the decision-making capacity, i.e. the ability to take responsibility for a specific choice. The option for a particular gradation of assertive care depends on the degree of decision-making capacity. The extreme form of care on the continuum is coercion. As this is the least obvious form of assertive outreach, caregivers apply additional criteria. In the case study we illustrate the ten degrees of assertive outreach. The caregivers always try to empower the client to take responsibility for a particular choice. CONCLUSION: This ethical view of assertive outreach is an addition to the legal framework and serves as an ethical reference for caregivers to draw up and apply a more refined and nuanced care plan.

[Assertive Treatment as a regular function within mental health]. / Van bemoeizorg naar assertieve behandeling als regulier aanbod vanuit de ggz.

BACKGROUND: The setting for providing assertive treatment (AT) has changed during the last 30 years in The Netherlands from assertive community treatment (ACT) and flexible assertive community treatment (FACT) to municipalities. The provision of AT varies between municipalities. AIM: Describing the concept of AT, the nature and size of the target group, and the reasons why people with severe mental illness (SMI) do not seek treatment and the place of AT in mental health care. METHOD: We used literature en available quantitative data. RESULTS: AT regularly provided by mental health care is required in patients with SMI and social problems who do not seek treatment. When mental health care and social care collaborate on the level of the patient, treatment and handling of social problems can strengthen each other. This collaboration prevents discontinuity of care and breaking a trusting relationship because patients do not need to be transferred from social service to mental health care or vice versa. AT is on the continuum of voluntarily to compulsory care.AT provided by mental health care (usually provided by FACT-teams) is indicated for SMI patients with social problems and who do not seek treatment. The size of the target group is around 5000 - 20.000 patients in The Netherlands. Reasons not to seek help for people with SMI include within person factor, mental health related factors, or factors related to the interaction of SMI patients and mental health. We advocate for AT to become a regular part of mental health care, and for mental health care and social domain professionals to collaborate on case level. Acting this way, mental health treatment and addressing social problems can reinforce each other and discontinuity of care and breaking a trusting relationship can be prevented. AT is on the continuum of voluntary to involuntary treatment. That is why we suggest AT to be a better term than assertive outreach. CONCLUSION: It is a given fact that not all patients with SMI and social problems seek treatment. By making AT a regular part of mental health services, we prevent discontinuity of care and we fill the gap between voluntarily and compulsory care.

[A relational ethical model for the assessment of decision-making competence in psychiatry]. / Een relationeel ethisch model voor het evalueren van beslissingsbekwaamheid in de psychiatrie.

BACKGROUND: Nowadays, partly due to legislation, decision-making competence is playing an ever-increasing role in psychiatry. So far, however, there are no clear criteria for evaluating the actual competence of the procedure.
AIM: To develop a relational ethical model, including criteria and methodology, which can be used to assess and enhance decision-making competence mainly from a relational and ethical perspective.
METHOD: Combination of a review of the literature and ethical reflection. First of all, a limited study was made of the literature relating to the concept of and criteria for decision-making competence. On the basis of the literature and relational ethical reflection, ten criteria were developed for decision-making competence and a method was devised for assessing the procedure.
RESULTS: The criteria that have to be satisfied can be summarised as follows: the persons involved must understand the information, and must be able to apply it to their own situation. They must be able to gain insight into their own situation and be able to weigh up the available options, and be able to estimate consequences for themselves, as well as for others. They must be able to motivate choices in a sensible and comprehensible manner without being subject to coercive influences coming from internal and external sources. Participants' choices should be motivated on the basis of their own personal values. The decision-making competence is assessed and enhanced by giving a score to the individual criteria and by making an overall evaluation. This is achieved by a dialogue including all the persons involved: the care seeker (as far as possible), close relatives and the care-providers.
CONCLUSION: The persons involved can attain greater objectivity by exchanging views orally on the ten proposed criteria for decision-making competence.

[An ethical reflection on outreaching mental health care]. / Een ethische reflectie op bemoeizorg in de geestelijke gezondheidszorg.

BACKGROUND: Care providers have a conflicting societal role: on the one hand they must respect the autonomy of individuals with psychiatric problems, but on the other hand they often feel the need to offer these individuals outreaching care. AIM: To compile an ethical reflection on some of the ways in which outreaching mental health care interventions can be provided in a responsible manner. METHOD: This ethical reflection is based on an ethical advice by the Ethics committee for Mental Health Care of the Brothers of Charity in Flanders. The method combines ethical discussion and a study of the relevant literature. RESULTS: A good starting point is a relational view of the human being that emphasises connectedness and involvement. Consequently, the care provider begins to intervene in the care programme by building a trusting relationship with the person with psychiatric problems. This is how these persons, their close family and friends and care providers exercise their responsibility. There is a gradation of responsibility that extends in a continuous line: personal responsibility develops into shared responsibility which can then become vicarious responsibility. On that basis there is also a gradation in the nature of outreaching care; the care providers first make themselves available and give information, then provide advice, negotiate, persuade, increase pressure, and finally take over and force the person with psychiatric problems. CONCLUSION: The care providers choose in dialogue and in a considered and consistent way for the appropriate form of outreaching care, in line with the degree of responsibility that the person with psychiatric problems can assume.

[Conditional shared confidentiality with regard to the exchange of information between members of a team or network; ethical advice needs to be updated]. / Het voorwaardelijk gedeelde beroepsgeheim bij het uitwisselen van informatie in een team of netwerk. Revisie van een ethisch advies.

BACKGROUND: Care-givers not only work as a team, but increasingly they also participate in networks. This development represents an ethical challenge to the exchange of information and to confidentiality. OBJECTIVE: To revise and update earlier advice formulated by the Ethics Committee for Mental Health Care of the Brothers of Charity in Flanders, in particular concerning the question of whether shared confidentiality can be extended from a team to a network. METHOD: The Ethics Committee applied an appropriate method which combined ethical discussion and literature research. RESULTS: The earlier advice is no longer adequate because of certain practical and theoretical grounds. The Ethics Committee chooses to take a positive view of the developing cooperation between care-givers and networks. Consequently, the committee proposes shared confidentiality, but links this to five conditions: (1) the care-givers should participate in a clearly defined and identifiable team or network, (2) they should have a caring task in common, (3) they should be pledged to confidentiality, (4) they should consult with the patient and obtain his/her informed consent, (5) they should apply 'the filter of relevance'. CONCLUSION: Care-givers can exchange information with members of a team or network, but this should be done on the basis of conditional shared confidentiality.

[Ethical advice on the prevention of suicide in mental health care]. / Ethisch advies over de preventie van zelfdoding in de geestelijke gezondheidszorg.

BACKGROUND: Professional carers are regularly confronted with clients who want to commit suicide. AIM: To develop ethical advice on the question how professional carers can provide ethically justified care that will prevent suicide. METHOD: The research method combines ethical discussion with a review of the literature. results According to the ethical advice, suicide is a manifestation of an existential crisis and is determined partly by the client's pathology. Three values are at stake in the prevention of suicide: the inviolability of life, the autonomy of the client and the care relationship between carers and their client. In order to integrate these values it is advisable to give attention to the following points. The best prevention consists of good care and a good care relationship involving intensive counselling of the client with regard to existential questions. In this way carers can increase the client's freedom and responsibility. Sometimes, however, carers need to come to protective agreements with the client or impose coercive measures in order to restrict the client's freedom. Such preventive measures must be accompanied by care for the carers themselves and the client's next of kin. CONCLUSION: By means of the integrating value of the care relationship carers should try to achieve a reasonable balance between the inviolability of life and the autonomy of the client.

Ethics of deliberation, consent and coercion in psychiatry.

In psychiatry, caregivers try to get free and informed consent of patients, but often feel required to restrict freedom and to use coercion. The present article develops ethical advice given by an Ethics Committee for Mental Health Care. The advice recommends an ethical ideal of shared deliberation, consisting of information, motivation, consensus and evaluation. For the exceptional use of coercion, the advice develops three criteria, namely incapacity to deliberate, threat of serious harm and proportionality between harm and coercion. The article also discusses the viewpoints of the ethical advice and of the European Convention on Human Rights and Biomedicine: is the advice in agreement with the Convention and can the advice refine the guidelines of the Convention for the particular context of psychiatry? Although the Convention emphasises the autonomy of the individual patient, whereas the advice focuses on the relationships between the partners involved, the advice enjoys a complementary and supportive function in the application of the Convention.

[Sharing information among carers involved in mental health care: ethical advice]. / Uitwisselen van informatie bij het samenwerken in de geestelijke gezondheidszorg: Een ethisch advies.

This article reproduces ethical advice given by the Ethical Committee for Mental Health Care set up by the Brothers of Charity in Flanders. The advice relates to the ethical problem that arises when several health care professionals and carers cooperate in mental health care: when and how should they share information about a patient or should information be kept confidential? The research on which the advice was based, consists of discussing ethical matters and studying the relevant literature. Two general principles emerged from the research, namely, consultation and carefulness. These principles are applicable in all situations. On every occasion the involved professionals and carers test whether patient information should be passed on. The test is conducted on the basis often carefulness criteria. The next step is to apply these general principles. If a team of carers is involved, then, it is argued, there should be shared confidentiality, the relevance of which undergoes a filtering process. On the other hand, when there is a network of professionals and carers and third parties are involved, consultation and carefulness should prevail, although exceptions can be made in certain circumstances.

Ethical dilemmas in community mental health care.

Ethical dilemmas in community mental health care is the focus of this article. The dilemmas are derived from a discussion of the results of a qualitative research project that took place in five countries of the European Union. The different stakeholders are confronted with the following dilemmas: community care versus hospital care (clients); a life with care versus a life without care (informal carers); stimulation of the client toward greater responsibility versus protection against such responsibility (professionals); budgetary control versus financial incentives (policy makers), and respect for the client versus particular private needs (neighbourhood residents). These dilemmas are interpreted against the background of a value based ethical model. This model offers an integral approach to the dilemmas and can be used to determine policy. The dilemmas are discussed here as the result of conflicting values-namely autonomy and privacy, support and safety, justice and participation, and trust and solidarity.

Interposition mesocaval shunt for chronic primary occlusion of the hepatic veins.

Five patients with primitive chronic Budd-Chiari syndrome were treated by Dacron interposed mesocaval shunts for medically uncontrollable ascites. In two instances, hepatomegaly and ascites disappeared for four and four and one-half years. In one patient with severe stenosis of the inferior vena cava, moderate ascites required tapping once a month one year later, despite proved prosthesis patency. In two patients, death occurred ten and 30 days after shunting due to thrombosis of the graft. Inferior vena cava stenosis appears to be the major factor for decision of opportunity and type of portacaval shunt. From our material, we can describe three types of stenosis: type I, due to caudate lobe hypertrophy, and type II, due to right lobe hypertrophy, are suitable for side-by-side portacaval or mesocaval shunts. Type III, regular and extended narrowing of inferior vena cava, observed in long term evolutive forms, is presumably due to fibrosis and is not a good indication for conventional infrahepatic shunting procedures. Since this study was completed, another patient had a side-to-side portacaval anastomosis for chronic Budd-Chiari syndrome without caval stenosis. The patient has been observed for seven months, and ascites did not reappear. This underlines the importance of a complete radiologic and hemodynamic preoperative study of inferior vena cava outflow impairment.

[The concentration of fetal cells in maternal haematopoietic organs during pregnancy. An experimental study in mice (author's transl)]. / Concentration de cellules foetales dans les organes hématopoïétiques maternels au cours de la gestation. Etude expérimentale chez la souris.

We have been able to show that fetal cells are able to survive and multiply in the haematopoietic organs of the pregnant mouse. We have been able to label fetal cells with a chromosome marker (T6) which is clearly visible in the metaphase of mitosis. It is not only that there is a considerable concentration of fetal cells in the maternal spleen (3 to 6 per cent) but there are several factors that suggest that these fetal cells can multiply there. These are, the presence of mitoses, long survival, and a rise in numbers in the case of a new pregnancy. Thus pregnancy seems to bring about a physiological "microchimerism".