Dilemma #5 side b


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Dilemma #5 side b

  1. 1. Dilemma #5<br />Side B<br />Explain what Max’s rights are and predict what his intentions were<br />Amie Starks<br />
  2. 2. What is the dilemma?<br />The dilemma in this scenario is whether or not Max should be PEC’d, even though he has been ruled mentally competent, and only a danger to himself.<br />What needs to be determined is whether or not a patient’s suicide attempt gives a physician the right to take away a patient’s autonomy?<br />
  3. 3. Who needs to be involved?<br />Max…because the patient should always be involved if possible, especially since he has been deemed mentally competent<br />The ER physician<br />Max’s psychiatrist, if available<br />Max’s family, is available<br />The hospital’s Ethical Committee<br />
  4. 4. Max, our 55 yr old patient<br />http://www.flickr.com/photos/16096540@N07/3593094023/in/photostream/<br />
  5. 5. Alternatives<br />The first alternative would be to have Max evaluated by his psychiatrist, and ask for his recommendation. This physician would know Max well, and could indicate if he thought a PEC was necessary.<br />The second alternative would be to ask family, if available, if they could assist in Max’s care after discharge. They could provide a safe environment, provide transportation to therapy appointments, and ensure he takes his meds.<br />The third alternative would be to admit Max into a psych facility, with his consent. They could change Max’s med regimen, to accommodate for the side effects that made him stop taking them, and led to this suicide attempt.<br />The fourth alternative would be, when able to, talk to Max, and find out his reasoning for his suicide attempts.<br />Getting Max involved in his care instills a sense of control, therefore opening up lines for communication and progressive therapy <br />Dictating his care to him, can further enforce his feelings of helplessness and despair<br />
  6. 6. Relevant Facts <br />Max is a 55 yr old male with history of three suicide attempts in the past 18 months, and the most recent by consuming rat poison.<br />He is well known to the ER staff.<br />He is divorced, alienated from his adult children, and chronically depressed.<br />After past evaluations, he was deemed competent, and a danger only to himself.<br />He has received psychotherapy and antidepressants, but stopped taking them due drowsiness side effect. <br />He is currently in the ER…incoherent and semiconscious.<br />The ER physician wants to PEC him for 72 hours.<br />
  7. 7. Assumptions<br />We assume that Max only has mental issues..how do we know that there is not a physiological underlying cause? Ex: brain tumor (causing chemistry upsets and limbic dysfunction)…MRIs, CTs?<br />Possible alcoholism (semiconscious state and incoherence)…did they do a urine drug screen on him, any labs? Often times, depressed victims turn to alcohol, and this can lead to the added effect of drowsiness with antidepressants. Has he ever been evaluated for alcoholism, explained the interaction of alcohol and antidepressants?? <br />We know that Max received therapy…but has he ever been in a psych facility..it only stated that he had psychotherapy, no inpatient status was mentioned.<br />
  8. 8. Maybe Max’s intentions were to get help (coping skills, medication change, getting in touch with family without calling them himself)?? Maybe he wanted to change his situation and didn’t know how or where to start? <br />After his last two attempted suicides, how were these discharges handled? Did the case manager/social worker have a detailed discharge follow-up plan in place for him? Including a support system, f/u appointments, who to contact if he had unpleasant med side effects or suicidal thoughts, suicide hotline numbers, suicide contract in place?<br />. <br />
  9. 9. Greatest Good-vs-Least Harm<br />The greatest good, in this scenario, refers to the keeping Max safe, while doing no harm…either by mental, physical, ethical or morally means.<br />However, if the ER physician PECs Max, he is doing harm…..he is robbing Max of his patient right of autonomy.<br />Autonomy, as defined by the Merriam-Webster Dictionary, is defined as the quality or state of being self-governing, or the right of self-governing.<br />www.merriam-webster.com/dictionary/autonomy my, <br />
  10. 10. Patients Rights, according to the American Hospital Association <br />The patient has the right to make decisions about the plan of care prior to and during the course of treatment and to refuse a recommended treatment or plan of care to the extent permitted by law and hospital policy and to be informed of the medical consequences of this action. In case of such refusal, the patient is entitled to other appropriate care and services that the hospital provides or transfer to another hospital. The hospital should notify patients of any policy that might affect patient choice within the institution.<br />In this case, Max has the right to be included in his plan of care, as well as the right to be transferred to a psych facility to receive more appropriate care, and the right to refuse ALL treatment!<br />http://patienttalk.info/AHA-Patient_Bill_of_Rights.htm<br />
  11. 11. Ethical Concern:PEC or not?<br />“Persons with mental health conditions deserve the same degree of personal autonomy as other citizens with disabilities when it comes to receiving services. This has not always been the case. For years, persons with mental health conditions have been combating the centuries-old stereotype that they are not competent enough to make their own decisions, or to be in charge of their own mental health care.  Today, we know otherwise, that persons with mental health conditions are not only capable of making their own decisions regarding their care, but that mental health treatment and services can only be effective when the consumer embraces it, not when it is coercive and involuntary. Involuntary mental health treatment is a serious curtailment of liberty.” http://www.nmha.org/go/position-statements/p-36<br />
  12. 12. Mental Treatment according to Mental Health America<br />“When involuntary treatment is used, it must be based on the following principles and understandings which are designed to ensure that the rights of persons with mental health conditions are protected:<br /> I. Presumption of Competency. A basic principle of law in the United States is that all adults are presumed to be "competent" - that is, they are presumed to be capable of making their own decisions about their own lives and their own medical care, including mental health treatment.<br /> II. Declaration of Incompetency. Every state has court procedures for determining when and if someone is incompetent. Only a tiny percentage of persons with mental health conditions have ever been declared incompetent under these procedures. This corresponds with the reality that almost all persons with even the most serious mental illnesses are competent most of the time - that is, they are capable of making their own decisions about whether to seek treatment and support and what treatment and support they should receive.”<br /> http://www.nmha.org/go/position-statements/p-36<br />
  13. 13. The Best Alternative?<br />When able, ask Max what he will or will not agree to.<br />Consider the evaluation by Max’s psychiatrist. Most people that enter the ER for emergency mental care agree to stay in the hospital, on a voluntary basis, after an in-depth conversation with their mental health provider. (http://en.wikipedia.org/wiki/Emergency_psychiatry) <br />
  14. 14. Implementation<br />After Max if awake and alert, has talked to his physiatrist, admit him, voluntarily, for 48 hours to observe for improvement.<br />Change med regiment, ensure compliance, monitor for unwanted side effects (to increase adherence).<br />PRIOR TO DISCHARGE… implement outpatient program consisting of:<br />Regular appointments with physiatrist<br /> Home visits with documentation of med compliance by mental home health<br />Support system (neighbors, friends, family) involved<br />Suicide Contract<br />Continued on next page…..<br />
  15. 15. What is a Suicide Contract?<br />Written contract with Max, stating that he will contact help if contemplating suicide…this is often times useful in suicidal patients (signed, dated, and sworn by the patient and caregiver)<br />They have been used by clinicians in the U.S. since 1973, and are growing in popularity among family members and friends of individuals who are or have been suicidal. <br />The first and most important section of no-suicide contracts is the unequivocal agreement that the individual signing the contract will, under no circumstances, die by suicide. Then the next section lists names and phone numbers that an individual needs to call if he or she becomes suicidal.<br />By the way, unlike traditional contracts which can be long, complex, and filled with abstruse legalese, no-suicide contracts need to be very short and easy to understand. Anything that is not necessary should not be put in the contract. <br />Please note that no-suicide contracts are not legal documents; <br /> they are agreements that outline what a person <br /> needs to do if he or she becomes suicidal. <br />http://www.suicide.org/no-suicide-contracts.html<br />www.boston.com/.../exhibitionist/contract.jpg<br />
  16. 16. Conclusion<br />Max is COMPETENT. This doesn’t mean he’s always made the right decisions, but it does mean he canmake his own decisions. <br />Autonomy is a patient right. If his autonomy is taken away, and he feels no control over his situation…have we not just added to the vicious cycle of his despair and hopelessness?<br />