Is this an ethical issue?

[sikegeek]

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I'm looking for a topic for my senior ethics paper and this something I saw on psych that disturbed me.

A college girl has a falling out with her boyfriend, impulsively takes tylenol and goes to bed. Didn't know how deadly it was. I forget how she ended up in the hospital, but she gets admitted to general medicine floor for mucomyst protocol.

She's humiliated and doesn't want to tell her parents or friends. She has no borderline features. She did this impulsive thing out of despair. She regrets what she did and agrees to see a therapist

Attending comes and tells her that if she does not consent to allowing him to call her roommate and specifically say "get guns and pills out of your apartment" that he will admit her to the psych ward- despite that she had to remain an inpatient for a few days anyway.

This really bothered me because he was basically telling her that he had to disclose the situation to her roommate or else.

Is this a possibly an ethical issue-even if I'm technically wrong to feel disturbed by it? Does anyone know where I could find out about legal requirements in this situation?

 

[Anasazi23]

These are forensic psychiatry concepts, known sometimes as "removal of method," or simply "negligence failure" to take reasonable steps to lessen the risk of a patient harming themself.

The misunderstood "duty to warn," which can be more accurately interpreted as "duty to do something," does not necessarily absolve the psychiatrist simply because she was admitted to a hospital.

Again, you can thank the lawyers and our litiginous society for this not-so-classic example of defensive medicine. Should this patient return to her apartment, repeat the gesture, or otherwise kill herself, the psychiatrist may have a much more difficult time defending himself that he took all reasonable precautions, since he did not admit the patient for observation to a psychiatric floor, and did not at least attempt to have removed, the object in her immediate environment that could cause her harm.

This is not to say that the patient could not decide to kill herself and go to the drug store and obtain a new bottle of acetaminophen, but again, this concept of having objects removed from an environment means something from a jury standpoint...and probably little else.

It reminds me of a "behavioral contract" that a nurse or doctor makes a patient sign stating that they will not harm themself in the hospital....essentially useless, but looks good on documentation.

 

[sikegeek]

Thanks for replying. I'm still not sure I understand. It sounds like he had good legal reasoning. He is a forensic psychiatrist by the way.

I guess I don't think disclosing information to her roommate was a "reasonable step." What if she didn't have a roommate? He put a stipulation on her privacy without really explaining her alternatives. Couldn't she be observed from a medical floor with a sitter? Being in the open psych unit does not seem THAT different from being on a medical floor, except it's quieter. He didn't expain that to her at all. He just said "you don't have to sign the consent, but you will have to go to the psych unit."

I thought it was poor style and it completely turned me off to forensic psychiatry. Don't patients sue doctors they don't like more often anyway?

 

[Therapist4Chnge]

It reminds me of a "behavioral contract" that a nurse or doctor makes a patient sign stating that they will not harm themself in the hospital....essentially useless, but looks good on documentation.

I was just reviewing a presentation on suicidology and self harm, and it was pretty critical of these types of contracts. For some it can be seen as coercive and have the opposite effect as desired, not to mention they offer the provider a false sense of security. I need to look up the references to see the research behind these assertions, but it seems to make sense.

It is sad how legalese has really done a number on provider care.

-t

 

[Therapist4Chnge]

Don't patients sue doctors they don't like more often anyway?

Patients will sue doctors period, though I'm guessing they may not have a problem suing someone they really don't like.

-t

 

[sikegeek]

I was just reviewing a presentation on suicidology and self harm, and it was pretty critical of these types of contracts. For some it can be seen as coercive and have the opposite effect as desired, not to mention they offer the provider a false sense of security. I need to look up the references to see the research behind these assertions, but it seems to make sense.

It is sad how legalese has really done a number on provider care.

-t

If you can find the sources, I would love to look them up. The approach seemed tacky to me. I don't know why I chose the word "tacky" but it just feels right in this situation.
I agree with the coercion thing- the patient is vulnerable and if they say they're not ready to disclose the situation to their family, I think they have the right to do that. If you feel they MUST be observed in a psych unit, don't attach that as a repercussion for not signing a consent for disclosure.

I saw the position that the physician put this girl in and I was horrified. She very clearly stated what she wanted and he came back at her as if this were a punishment. I thought it was good to encourage de-sigmatization of psychiatry, not threaten vulnerable patients with it.

 

[Therapist4Chnge]

If you can find the sources, I would love to look them up.

I have the general references used for the presentation, but the specific slides didn't denote which reference(s) the info was pulled from. I'll be seeing one of the presenters on Monday, I'll ask him where it came from. If you don't want to wait, here are the references:

References

Berman, A.L., Jobes, D.A., & Silverman, M.M. (2006). Adolescent suicide: Assessment and Intervention, 2nd Edition. Washington, DC: APA.

Lieberman, R. & David, J. (2002). Suicide intervention, In S.E. Brock, P.J. Lazarus, & S.R. Jimerson (Eds). Best practices in school crisis prevention and intervention (pp.531-554). Bethesda, MD: National Assoc. of School Psychologists.

Lieberman, R., & Poland, S. (2006). Self-Mutilation. In G. Bear & K.Minke (Eds), Children's needs III (pp.965-976). Bethesda, MD: National Assoc. of School Psychologists.

Lieberman, R., Poland, S. & Cassel R. (in press) Suicide Intervention. In Thomas, A. & Grimes, J. Best practices in school psychology V. Bethesda, MD: National Assoc. of School Psychologists.

Miller, D.N. & McConaughy, S.H. (2005). Assessing risk for suicide. In S.H. McConaughy. Clinical Interviews for children and adolescents (pp. 184-199). New York: Guilford.

Poland, S. & Lieberman, R. (2002). Suicide Intervention. In Thomas, A. & Grimes, J. Best practices in school psychology IV. Bethesda, MD: National Assoc. of School Psychologists.

-t

 

[sikegeek]

Thanks!!!

 

[Anasazi23]

Thanks for replying. I'm still not sure I understand. It sounds like he had good legal reasoning. He is a forensic psychiatrist by the way.

I guess I don't think disclosing information to her roommate was a "reasonable step." What if she didn't have a roommate? He put a stipulation on her privacy without really explaining her alternatives. Couldn't she be observed from a medical floor with a sitter? Being in the open psych unit does not seem THAT different from being on a medical floor, except it's quieter. He didn't expain that to her at all. He just said "you don't have to sign the consent, but you will have to go to the psych unit."

I thought it was poor style and it completely turned me off to forensic psychiatry. Don't patients sue doctors they don't like more often anyway?

You really can't let this turn you off to forensic psychiatry in general...as this is really something that every inpatient or C/L attending must go through almost daily at a busy hospital. The fact that he was a forensics expert doesn't really change much in terms of that.

Quite frankly, my license is worth more to me than the proverbial letting someone off the hook, or not inconveniencing someone who has made an attempt and I'm waffling on what to do with them. When in doubt, I [usually] err on the more conservative decision. Though unfortunately, this can lead to legal entanglements as well.

Allowing someone who has made a suicidal gesture/attempt/parasuicidal attempt to go home without supervision or without taking some external precaution will bode poorly for the physician in court. I don't blame you for disliking the outcome of that particular case or his decision, but these types of things commonly happen.

You say she wasn't borderline...by definition, she has made a borderline gesture. She likely is not the most stable person on earth. It's these same types of patients that will go home, make another attempt, then have either her or her family breathing down your neck with subpoenas asking why you didn't take further measures to protect their daughter.

 

[sikegeek]

OK, but it felt really wrong to me. Either way I guess it's not a good topic to write an ethics paper about.

 

[luft]

Yeah, I was going to say the whole suicidal gesture thing sounds a bit borderline to me. This is one of those situations where confidentiality takes a back seat to safety. It could be (and has been) argued that this is more of a gesture meant to appease juries than anything that will keep the patient safe, but it also sends a message to the patient that what she did is very, very serious. It also forces something out into the open where it can be worked on (albeit in a more traumatic way that most of us would choose). There is more going on here than just her breaking up with her boyfriend. Things like this bug me too, ever since HIPAA has been seared onto my soul, but I think it is ultimately better for the patient.

 

[Therapist4Chnge]

If you can find the sources, I would love to look them up.

I talked with one of the presenters today, and he told me it was the citation in press right now, though I did some poking around and found research (Am J of Psychiatry 2000 article) that has been referenced a few different places. It isn't a great study, but it has some worthwhile information in it.....and it is free to read!

Use of No-Suicide Contracts by Psychiatrists in Minnesota (PDF)

I am suppose to be getting some more research/info on the topic from the presenter, and I'll post some references if anything interesting comes up.

-t

 

[Milo]

impulsively... tylenol

Look at those two words again. You think she's good to go because she's been embarrassed?

fwiw I generally tell patients something along these lines. What you tell me I don't tell anyone else, unless you are planning on hurting yourself or others. Then I tell everyone.

Engaging her social support (despite her chagrin) and removing means is the standard of care, not unethical behavior.

 

[Solideliquid]

Do you know how much she took? Are we talking three pills and some attending in the ED jumps the gun and admits? The whole bottle? Half?


?

EDIT: From experience - A woman takes an extra klonopin to get to sleep after a fight with husband. He calls 911, she is taken to the ED. The ED attending is jumping up and down for me to admit. Geez. My attending is no help, I can almost make a haiku about this situation.

 

[Therapist4Chnge]

I can almost make a haiku about this situation.

*waits patiently for the haiku*

-t

 

[Solideliquid]

Grrr...


-Fighting sleepless night

-GABA open 9-1-1

-Attending no help


(ok it's 12:30am here)

 

[Therapist4Chnge]

*bows to SeL*

You are both sleepless and a scholar!

-t

 

[sikegeek]

Look at those two words again. You think she's good to go because she's been embarrassed?

fwiw I generally tell patients something along these lines. What you tell me I don't tell anyone else, unless you are planning on hurting yourself or others. Then I tell everyone.

Engaging her social support (despite her chagrin) and removing means is the standard of care, not unethical behavior.

I really just wanted to find out if this was an ethical topic for me to write a paper about. I might feel differently when I actually have some responsibility, but right now all I have to go on is my naive little impression.
I haven't really seen anyone comment on HER rights, her right to privacy, her right to be informed about her options. I know she loses rights if she plans to hurt herself or anyone else, but she stated that she no longer planned to do so.
The other part that you can't see is how this attending was talking about her as if she was a criminal. I thought she deserved more compassion. She was hurting.
Of course I can't say she is definitely not borderline. When I think of borderline, I think of a long-standing pattern of behavior and unstable relationships. I didn't appreciate anything like that in her.

I'm a student. My opinion is naive and relatively uninformed. I know that. I just want to write a paper about something I care about and not some random thing I would have to make up (like everyone else does.)

 

[sikegeek]

I talked with one of the presenters today, and he told me it was the citation in press right now, though I did some poking around and found research (Am J of Psychiatry 2000 article) that has been referenced a few different places. It isn't a great study, but it has some worthwhile information in it.....and it is free to read!

Use of No-Suicide Contracts by Psychiatrists in Minnesota (PDF)

I am suppose to be getting some more research/info on the topic from the presenter, and I'll post some references if anything interesting comes up.

-t

thank you so much!

 

[sikegeek]

Do you know how much she took? Are we talking three pills and some attending in the ED jumps the gun and admits? The whole bottle? Half?


?

EDIT: From experience - A woman takes an extra klonopin to get to sleep after a fight with husband. He calls 911, she is taken to the ED. The ED attending is jumping up and down for me to admit. Geez. My attending is no help, I can almost make a haiku about this situation.

No, she should have been admitted. I think 20 or something. She had to be in the hospital anyway. I felt he was threatening her with "admission to the psych ward" as if it was this horrible thing. I just saw her as vulnerable and not understanding her options.

 

[billypilgrim37]

I'm a student. My opinion is naive and relatively uninformed. I know that. I just want to write a paper about something I care about and not some random thing I would have to make up (like everyone else does.)

As another student, I think you should ABSOLUTELY write your paper on this topic. But also include another aspect, your personal countertransference. Have you had negative experiences with the attending otherwise? Does something about this girl's case make you identify with her in anyway? The latter is probably inevitable, if only for proximity of age. It's okay to have those feelings. It's just not okay to not recognize where they enter your decision making process. It's also not okay to use double negatives

The facts of the case you present to us delineate pretty reasonable, if a bit callous, behavior on the part of the attending. The personal impressions you give us suggest otherwise. That means SOMETHING. It doesn't mean you are wrong, and it doesn't mean the attending is wrong, but it does mean that this is fertile ground for you to do some personal and professional exploration.

For example: Lots of people have fights with their boyfriends and don't take tylenol, so no matter how she seems now, the pre-test probability of this girl having some impulsivity issues is through the roof. But you give her a free pass, and you entreat us to do the same. Why? Maybe it's simply because you're a compassionate human being, and like me, lack enough experience to separate a healthy sense of compassion from a healthy clinical acumen. That right there is your ethics paper. Or there are a dozen other ways you could go. But do this! You obviously care about it (in a very healthy way), and you demonstrate you're more than capable of parsing your own dissonance with the help of a few cups of coffee.

Good luck!

 

[OldPsychDoc]

...capable of parsing your own dissonance with the help of a few cups of coffee.

Now if that isn't a worthy goal for me today, I don't know what is!

 

[sikegeek]

As another student, I think you should ABSOLUTELY write your paper on this topic. But also include another aspect, your personal countertransference. Have you had negative experiences with the attending otherwise? Does something about this girl's case make you identify with her in anyway? The latter is probably inevitable, if only for proximity of age. It's okay to have those feelings. It's just not okay to not recognize where they enter your decision making process. It's also not okay to use double negatives

The facts of the case you present to us delineate pretty reasonable, if a bit callous, behavior on the part of the attending. The personal impressions you give us suggest otherwise. That means SOMETHING. It doesn't mean you are wrong, and it doesn't mean the attending is wrong, but it does mean that this is fertile ground for you to do some personal and professional exploration.

For example: Lots of people have fights with their boyfriends and don't take tylenol, so no matter how she seems now, the pre-test probability of this girl having some impulsivity issues is through the roof. But you give her a free pass, and you entreat us to do the same. Why? Maybe it's simply because you're a compassionate human being, and like me, lack enough experience to separate a healthy sense of compassion from a healthy clinical acumen. That right there is your ethics paper. Or there are a dozen other ways you could go. But do this! You obviously care about it (in a very healthy way), and you demonstrate you're more than capable of parsing your own dissonance with the help of a few cups of coffee.

Good luck!

Thanks -I thought that was really constructive. A great idea. The whole transference thing- the guy really does bother me in a number of ways. I guess I have high expectations for psychiatrists as far as being really compassionate and knowing how to deal with people compassionately. He bothered me in a number of other ways. He told this particular girl that he wanted to call because otherwse she would be a liability to him. Isn't that a little weird?

He also tried to interview a catatonic patient when they were sitting on their bedside commode, which I thought was really weird.