For Lack of a Better Plan: A Framework for Ethical, Legal, and Clinical Challenges in Complex Inpatient Discharge Planning Content Type Journal Article Pages 311-326 DOI 10.1007/s10730-009-9117-6 Authors Jane Jankowski, Albany Medical Center Albany NY 12208 USA Terese Seastrum, Northeast Health 2212 Burdett Ave. Troy NY 12180 USA Robert N. Swidler, Northeast Health 2212 Burdett Ave. Troy NY 12180 USA Wayne Shelton, Alden March Bioethics Institute, Albany Medical College 47 New Scotland Avenue, MC 153 Albany NY 12208-3478 (...) USA Journal HEC Forum Online ISSN 1572-8498 Print ISSN 0956-2737 Journal Volume Volume 21 Journal Issue Volume 21, Number 4. (shrink)

Not all hospital inpatients need the level of care uniquely available in the acute-care setting. In the United States, these longer-term, nonacute inpatients tend to be some combination of chronically ill, poor, homeless, undocumented, uninsured, and disabled—all groups who have struggled for health equity, political recognition, and voice. Even so, these “permanent patients” continue to receive care in one of the most expensive settings. This phenomenon is the result of federal legislation that creates an affirmative duty to care for all (...) able to access our emergency departments without also making safe housing available to all. A handful of federal laws and policies as well as a potpourri of state laws and policies are involved. (shrink)

How do we respond to the patient who no longer needs inpatient care but refuses to leave the hospital? Complex hospital discharges commonly involve consideration of legal, financial, clinical, and practical issues. Yet, the ethical and contextual issues embedded in complex inpatient discharges are of concern and have not received adequate attention by medical ethicists. The aim of this work is to encourage clinicians and administrators to incorporate a justice rubric when approaching inpatient discharge dilemmas. This (...) paper presents justice as the ethical principle most neglected in situations involving complex discharges and suggests that a justice focused lens allows clinicians and administrators to move beyond notions of patient autonomy in crafting morally responsible hospital discharge decisions that reflect efficient stewardship of an appropriate share of medically indicated services. This issue deserves additional attention from medical ethicists in the future. (shrink)

Discharge planning for vulnerable infants and children is a collaborative, inter-disciplinary, decision-making activity that is grounded in the ethical complexities of clinical practice. Although it is a psychosocial intervention that frequently causes moral distress for professionals and has the potential to inflict harm on children and their families, the process has received little attention from ethicists. An ongoing study of the transition of technology-dependent children from hospital to home suggests that the ethical issues embedded in the discharge- (...) class='Hi'>planning process may be concealed by dominant cultural values, institutional policies, clinical standards, historical precedents, and legal regulations. (shrink)

In any healthcare system in which demand exceeds supply—which means any typical public healthcare system—patients cannot always get the care they want or need when they want or need it. It is also unrealistic to suppose that it will ever be otherwise. There have been such advances in medicine and growth in the population that even if we forgot about all other goods such as education, roads, social services, and so forth and put the entire budget into healthcare, there would (...) still be a gap between supply and demand. Moreover, even if we could by that expedient make them match and had eyes only for health, we still should not. For it is now understood that healthcare is the least important determinant of health, lining up well behind poverty and social status. But if suboptimal care is to be our destiny, we must plan how it is to be delivered. (shrink)

This is a complex case of a younger man with unclear social supports and a disabling diabetic infection that is limiting his ability to be and possibly feel productive. The patient appears to be ha...

In lieu of an abstract, here is a brief excerpt of the content:Joint and Grief AchesHeer HendrySomething that surprised me when I started my clinical rotations in medical school was how often we discussed proper footwear. In the lulls of rounds, I've heard healthcare providers talk about how worn-down shoes or inadequate arch support have caused them joint and back pains. We spend hours on our feet and bring the aches home with us, a reminder of our workday as we (...) walk our dogs or grocery shop. Embarrassingly, this is what was on my mind as I was starting a 12-hour shift wearing a new pair of shoes that an ICU nurse had recommended.It was the third day of my emergency medicine rotation, and my team received descriptions and plans for the 23 patients in the department precisely at 0700. I scribbled notes about each patient on my notepad, learning to distinguish which aspects of each patient were important to carry into this next shift for good continuity of care. For one patient, my note read: "aspiration, sepsis, hospice."My resident and I walked into each room and introduced ourselves, confirmed their story, and updated them on the next steps that we would be working on. The 4th patient on our list was the one I noted above—an 87-year-old male who was brought in after repeated bouts of emesis (vomiting) and choking. This was his fifth hospital visit this year for similar chief complaints, two of which resulted in ICU stays. Hours earlier, his two sons and two daughters had made the decision to place him on hospice.Upon entering the room, I saw an elderly patient lying on a stretcher with his eyes closed, grimacing and breathing rapidly. There was a younger man at his bedside staring at the patient while drumming his fingers on a coffee cup from a gas station next to the hospital. He didn't notice us walk in and was startled as we began to introduce ourselves. He identified himself as the patient's son, telling us he had just arrived at the hospital but had been on a conference call with his other siblings and palliative care earlier. His eyes darted between us and his father's rapid, shallow breaths.We updated him on his father's condition, explaining that we'd been making him comfortable with morphine and benzodiazepines. We talked about his blood lactic acid, his electrolytes, and his feeding tube. He continued drumming his fingers on the cup and nodding as we discussed trying to find an inpatient bed for his father. We informed him about the unpredictability of how much longer he would be alive and the unlikelihood of discharge. We asked if we could answer any questions for him, and he shook his head, but as we opened the door to leave, he asked: "So, the morphine is shutting down his body, right?" We clarified the purpose of the morphine, explaining that the morphine was making him comfortable and pain-free, but that his body was shutting down on its own."But in a way I'm still killing him?" he asked. My chest squeezed tight at that question. My goal for this patient immediately changed from getting him a bed in the inpatient unit to convincing his son that he was not harming his father. We started from the beginning and explained the lab markers and prognosis once again and asked if he'd like to speak to palliative care in person. He simply nodded as we exited to give him privacy.Leaving that room, it was barely 7:00 am. We still had 19 other patients to check on. My chest was still tight, but I could not allow my mind to remain in that room while the other patients were still pending exams, workups, and admissions. I acknowledged to myself that reflection would have to occur later, and yet, as we walked to the next [End Page e16] room, I wondered if the resident I was with had lost anyone in his life as I have in mine. Seeing the son trying to process and understand the situation in real time triggered my memories of past times... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:How Policies and Practices in Medical Settings Impact Communication Access with Deaf Patients and CaregiversKelley Cooper, Maggie Russell, Debra Chaiken, Michael W. Mazzaroppi, and Gretchen RomanIntroductionWe are a group of Deaf community members, sign language interpreters, organizational leaders, and academic partners. We have a collective point of view about how policies and practices in medical settings impact communication access with Deaf patients and caregivers. Here, we account multiple stories (...) from our respective experiences in an effort to improve healthcare institutions' awareness of the recommended modalities when communicating with Deaf patients accessing care. Our stories clarify any misunderstandings about communication with Deaf patients who expressively use spoken language and receptively use sign language. We convey that it is imperative to use visual language when explaining discharge paperwork and emphasize that it is critical for a Deaf caregiver to be fully aware of the plan of care when offering support to their loved one. We illustrate the importance of honoring the requests for in-person sign language interpreting versus video remote interpreting (VRI) as well as requests for Deaf-Hearing sign language interpreter teams. Deaf interpreters bring formative cultural, linguistic, and life experiences and work in partnership with a hearing interpreter to provide a more nuanced communication exchange across a wide range of visual languages.Maggie Russell: Anecdote 1The hospital recidivism rate for a Deaf Nepali male patient continues to increase. As the Interpreter Referral Service Director, I am aware of this patient because he receives care management services from our organization. He has several life-threatening conditions, attends dialysis, is on multiple medications, and is frequently in and out of the local hospital. The hospital considers him as someone who identifies as an oral Deaf person, as he has severe to profound hearing loss with little or no residual hearing and visually receives signed language but expressively uses spoken language. Three interpreters, a spoken Nepalese interpreter, a Deaf Nepali Sign Language (NSL) interpreter, and a hearing American Sign Language (ASL) interpreter, working together as a team are recommended for effective communication with this patient and the medical team of providers. However, interpreting services at the hospital provide only one interpreter, a spoken Nepalese interpreter, which [End Page E3] does not satisfy the necessary accommodations for access. A plethora of prescriptions were added to his regimen to counter the condition that caused a recent inpatient stay. The patient's wife is his primary caregiver. She communicates receptively and expressively using NSL. A Deaf NSL and hearing ASL interpreter team creates effective communication with his wife and the medical team of providers. Since she is expected to follow the doctor's recommendations as explained in the discharge instructions, she also requires accommodations for communication access. Neither the patient nor his wife received a formal education, and they do not read or write English or the language of their country of origin. Therefore, information in English or Nepalese conveyed in the printed discharge paperwork is inaccessible. The new medications were not incorporated into his already established monthly "pill pack," and the couple was unable to read the information on the pill bottles that were delivered to their home. Subsequently, incorrect use of the newly prescribed medications significantly delayed the patient's course of recovery. This couple also had minimal exposure to medical information and medical processes prior to living in the United States; the medical services in the refugee camps in Nepal were typically non-existent. Utilizing a hearing ASL interpreter alone does not constitute barrier-free access for either of these individuals. Interpreting medical documents in a visual format is so critical for providing access, but it doesn't necessarily guarantee comprehension because of their limited health literacy. In addition to employing the recommended interpreting team, using teach-back methods during an encounter is a good way for medical providers to ensure the patient and caregiver's understanding of the plan of care.Maggie Russell: Anecdote 2As the Interpreter Referral Service Director at our organization, I served as the hearing interpreter on a Deaf-Hearing ASL interpreter team at a follow-up gastrointestinal appointment from a gall bladder biopsy for a Deaf male patient, along with his Deaf... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Tincture of the Doctor's TimeHolland KaplanI first thought of Mr. H as a "difficult patient" while reading the written hand-off I received on him as I was preparing to take over an inpatient general medicine service—"He leaves all the time to smoke." I don't think the statement was meant to imply anything about the patient; if anything, it may have been included for context to prepare me (...) for the patient's intermittent absence. But, reading this, I felt a familiar sense of annoyance rising in my chest. Every few months, I take care of a patient who seems to never be in his room. The patient is consistently out smoking, in the cafeteria, or in another unknown location, seemingly doing an undisclosed activity. This is frustrating because it means I have to work around the patient's schedule of smoke breaks and jaunts to the cafeteria to evaluate the patient on a daily basis. The thoughts inevitably cross my mind: Does this patient even want care in the hospital if he's never in his room? Is he actually sick enough to need to be in the hospital if he's able to spend so much time outside of the hospital? Why is he leaving so frequently—is he doing drugs?This particular patient had been in perfect health until two months before I met him when he was shot multiple times during an encounter at a gas station. One of the bullets had lodged in his back, shattering a vertebra. Another had decimated the bones in his right upper arm, which were now held in place by screws and plates. Several had landed in his abdomen, necessitating the removal of part of his bowel. Finally, a bullet had sliced through the lower part of his right kidney, shredding his ureter and mandating surgical reconstruction of his urinary system. After over a month in the intensive care unit with multiple reparative surgeries, he was discharged to a rehabilitation facility. But he started having fevers and fast heart rates; ultimately, he was admitted to the hospital again for multiple infected fluid collections that had formed at the sites of his surgeries. He left the hospital prior to getting treated for these infections, purportedly "against medical [End Page 12] advice." And now, several weeks later, he was here in the hospital for the same reason.The first time I went to see Mr. H, he was, of course, not in his room. I went to the nursing station to ask if the clerk knew where he was. She knowingly said, "Oh yeah, he goes out a lot. I can give him a call to let him know the doctor is here to see him if you'd like." I assented, thanked the clerk for calling him, and proceeded, annoyed, in seeing the rest of my patients. I considered how I would address Mr. H's behavior when I was finally able to talk to him. I had seen others take many different approaches—negotiation about the timing and frequency of these extramural expeditions, ultimatums about getting discharged, mandating urine drug screens upon return, and silent, frustrated tolerance. I resolved to wait to speak to him to determine which approach might be most suitable. An hour later, I received a call from the clerk that Mr. H had returned to his room to see me.The first time I met Mr. H, he informed me he had taken the bus to midtown to make a run to the grocery store. I was internally incredulous. He felt well enough to go to the grocery store? Why was he in the hospital then? At that moment, I opted not to discuss his frequent departures yet, as I was frustrated and realized I wouldn't be able to identify the best way to address them. I reviewed his medical issues with him, asked specific questions about how he was feeling, performed a physical exam, and reiterated his current plan of care. Mr. H made it very clear that he would like to get out of the hospital as soon as possible. I tried to set the expectation that he... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:When Is Enough, Enough?Megan HomsyThis was a case that stuck with many members of our transplant team for a long time. The patient was a 44-year-old Caucasian male evaluated for a liver transplant with a diagnosis of hepatitis C virus (HCV), originally diagnosed 11 years before the transplant evaluation. The patient met the criteria for the following substance use diagnoses: alcohol use disorder moderate in sustained remission, in a (...) controlled environment, opioid use disorder, severe, in sustained remission, on maintenance therapy, in a controlled environment, stimulant use disorder, amphetamine-type, severe, in early remission, in a controlled environment and stimulant use disorder, cocaine-type, severe in early remission, in a controlled environment.The patient had been living in a sober living housing program for approximately ten months prior to his transplant evaluation with me, his social worker. He had also been diagnosed with depression and bipolar disorder. He had been intermittently linked with mental health services and had participated in numerous detox and substance abuse programs over the last ten years, with varying degrees of success. He was in dual diagnosis treatment (i.e., treatment for co-occurring substance use and mental health disorders) through his Suboxone clinic and was completing toxicology screenings on a biweekly basis.After concluding the minimum three months of drug and alcohol treatment set forth by the state's Organ Transplantation Consortium, the patient graduated from his sober living program, moved in with his sister, and was listed for a liver transplant.The patient was transplanted five months after his clinic evaluation. At the time of the surgery, the patient's Suboxone was abruptly discontinued and replaced with IV Dilaudid. Within days of his transplant, the patient frequently expressed concerns about his pain. Several medical services attempted to manage the pain medications, resulting in his pain management plan being changed repeatedly and much confusion over his current medication regimen. During his liver transplant hospitalization, the RN found the patient with a needle in his arm, and after a search of the patient's hospital room, the hospital police found drug paraphernalia and illicit substances. The patient was eventually discharged to an inpatient substance abuse program, which he left before completing the program and against medical advice.During his first year post-transplant, I attempted to arrange other various treatment programs for him (most of which he did not follow through with) and to find housing for him (as he had been forced to leave his sister's home after his relapse). Eventually, the patient was incarcerated on drug-related charges. Numerous times, the patient missed completing his labs and his post-transplant appointments. He did not refill his immunosuppressant medications, and for lengthy periods of time, he was unreachable by the transplant care team, which resulted in my team members and I calling the patient's family, other providers, and the police for safety checks.In the aftermath of these issues, my colleagues and I had to reckon with the realization that we had failed the patient. As a team, our transplant center created a task force to review this case and what to do in the future to prevent such breakdowns in patient care. We created protocols for managing patients who, at the time of their transplant, are on Medication Assisted Treatment (MAT) such as Suboxone and methadone. Staff across the multidisciplinary team attended trainings regarding addiction, pain management, and best practices for MAT services. Additionally, our transplant center collaborated with our hospital's addiction treatment program for a streamlined referral process for transplant patients to addiction services.This patient's case and its sensational nature resulted in many conversations, both professional and unprofessional. Members of the social worker department became aware that personnel within transplant, though not involved in patient care, were inappropriately discussing this patient's case and engaging in unprofessional behavior. Said actions led to the termination of a member of the transplant team. I was placed in the unenviable [End Page E3] position of having to report this behavior to hospital management and legal teams to protect a vulnerable patient.The ethical challenge behind this case really stems from the transplant team attempting to balance two... (shrink)

Collaboration among nurses and other healthcare professionals is needed for effective hospital discharge planning. However, interprofessional interactions and practices related to discharge vary within and across hospitals. These interactions are influenced by the ways in which healthcare professionals’ roles are being shaped by hospital discharge priorities. This study explored the experience of bedside nurses’ interprofessional collaboration in relation to discharge in a general medicine unit. An ethnographic approach was employed to obtain an in‐depth insight into (...) the perceptions and practices of nurses and other healthcare professionals regarding collaborative practices around discharge. Sixty‐five hours of observations was undertaken, and 23 interviews were conducted with nurses and other healthcare professionals. According to our results, bedside nurses had limited engagement in interprofessional collaboration and discharge planning. This was apparent by bedside nurses’ absence from morning rounds, one‐way flow of information from rounds to the bedside nurses following rounds, and limited opportunities for interaction with other healthcare professionals and decision‐making during the day. The disconnection, disempowerment and devaluing of bedside nurses in patient discharge planning has implications for quality of care and nursing work. Study findings are positioned within previous work on nurse–physician interactions and the current context of nursing care. (shrink)

Discharging a homeless patient from hospital raises ethical issues which are compounded when the patient is from outside the United Kingdom. This article begins with an extended case study of a 30-year-old homeless man from Lithuania describing his complex medical and social needs. It is best practice for all homeless patients to have their housing needs planned for prior to discharge, but this is made more difficult by the United Kingdom’s ‘hostile environment’ policy which creates a subclass of homeless (...) people who are not eligible for support. This means healthcare professionals discharge patients back to homelessness, even when this is likely to adversely affect their health and dignity both directly and indirectly through impairing access to care for chronic conditions. Policies in health and social care which compel professionals to treat some patients with second-class care undermine the ethics of healthcare professions. (shrink)

Volume 19, Issue 10, October 2019, Page 93-94.

The ethical obligation to provide a reasonably safe discharge option from the inpatient setting is often confounded by the context of homelessness. Living without the security of stable housing is a known determinant of poor health, often complicating the safety of discharge and causing unnecessary readmission. But clinicians do not have significant control over unjust distributions of resources or inadequate societal investment in social services. While physicians may stretch inpatient stays beyond acute care need in the (...) interest of their patients who are experiencing homelessness, they must also consider the implications of using an inpatient hospital bed for someone without the attendant level of medical need. Caring for patients in an inpatient setting when they no longer require acute care means fewer beds for acute care patients. And when a patient who is experiencing homelessness declines a medically safer option such as a skilled nursing facility, then clinicians may be faced with the sole option of discharge to the street, which raises troubling questions of nonmaleficence and social justice. Here we investigate the different forms of injustice that play out when patients are discharged to the street, and offer a map of the interwoven ethical responsibilities of clinicians, hospitals, and skilled nursing facilities. (shrink)

Sending patients “home to fail” while anticipating their speedy readmittance is, prima facie, ethically troubling as are all unsafe discharges. However, “home to fail” cases may also be covertly ethically troubling insofar as they raise questions of medical paternalism due to a motivational component which drives these types of cases: by discharging a patient “home to fail” she will come to appreciate that living at home is unsafe and thus unwise, prompting her to choose differently in the future.

Using conversation analysis, this study investigates how Japanese rehabilitation team members use their geographic knowledge to search for long-term care facilities for stroke survivors in multidisciplinary team interactions. The study uncovers the orderly use of decision rules during discharge planning activities by exploring the following two questions: What decision criteria are discursively used? In what order are the criteria handled through sequential operations? The data comprise 65 video-recorded rehabilitation team meetings and ethnographic information regarding local care facilities and (...) patients’ residential addresses. The analysis shows that the participants deal with decision criteria in an orderly manner. They identify the type of facility and location preferred by the patient’s family and search for a facility accordingly. Moreover, they routinely select facilities closer to the patients’ and their families’ homes. However, these rules are modified if the family’s choice is inappropriate, or when a facility in a different location is preferred by the family. The study contributes to the conversation analytic understanding of interprofessional decision making and prioritization through the analysis of orderly methods of search procedures interactively accomplished by participants in ongoing medical team interactions. (shrink)

Every day around the country, patients are discharged from hospitals without difficulty, as the interests of the hospital and the patient tend to align: both the hospital and the patient want the patient to leave and go to a setting that will promote the patient’s continued recovery. In some cases, however, this usually routine process does not go quite as smoothly. Patients may not want to leave the hospital, or they may insist on an unsafe discharge plan. In other (...) cases, there may simply be no good place for the patient to go. These complex hospital discharge situations often involve ethical, legal, financial, and practical considerations, but the ethical issues inherent in these dilemmas have received only sporadic attention from clinical ethicists at best, leaving patients, providers, administrators, and caregivers unsure about what to do. When the ethical issues are in fact brought to light, analysis usually proceeds based on a consideration of the principles of autonomy, beneficence, nonmaleficence, and justice. However, principled analysis often fails to present patients and providers with a satisfactory solution, as the principles inevitably conflict. In this paper, I argue that difficult discharges are ethical dilemmas worthy of scholarly attention that goes beyond principlism, and I argue that providers and those involved in discharge planning ought to cultivate what philosopher Alasdair MacIntyre calls “virtues of acknowledged dependence” in order to care for these patients and their families. I first trace the current conversation about difficult discharge and show that the principled approach to resolving discharge dilemmas is not sufficient. I then argue that a new approach is needed, and to that end, I offer practical ways in which MacIntyre’s account of the virtues of acknowledged dependence may help patients, providers, and family members to navigate issues of difficult discharge. (shrink)

As a tool for regulating the environment in China, does environmental information disclosure reduce pollutant discharge? To answer this question, we empirically analyzed the emission data of “the three wastes” in unit industrial GDP in 31 provincial units. As a measure to reduce institutional emission, environmental information disclosure only slightly influenced waste discharge reduction in the implementation period of the Eleventh Five-Year Plan of China. Instead, command control and market-based tools significantly affected waste discharge reduction. Representative measures (...) included penalties and charges. With the continuously enhanced pressure of control, environmental information disclosure facilitates the effects of command control tools on waste discharge reduction. Content analysis of environmental information disclosed by sample listed companies in Jiangsu Province was conducted. The disclosure of insufficient environmental information on emission reduction can be attributed to “adverse selection” in system performance and to the limited quality of overall environmental information disclosure. This study provides empirical evidence for Chinese policy makers to improve the system for environmental information disclosure of listed companies. (shrink)

Some of the most difficult consultations for an ethics consultant to resolve are those in which the patient is ready to leave the acute-care setting, but the patient or family refuses the plan, or the plan is impeded by deficiencies in the healthcare system. Either way, the patient is “stuck” in the hospital and the ethics consultant is called to help get the patient “unstuck.” These encounters, which we call “complex discharges,” are beset with tensions between the interests of the (...) institution and the interests of the patient as well as tensions within the ethics consultant whose commitments are shaped both by the values of the organization and the values of their own profession. The clinical ethics literature on this topic is limited and provides little guidance. What is needed is guidance for consultants operating at the bedside and for those participating at a higher organizational level. To fill this gap, we offer guidance for facilitating a fair process designed to resolve the conflict without resorting to coercive legal measures. We reflect on three cases to argue that the approach of the consultant is generally one of mediation in these types of disputes. For patients who lack decision making capacity and lack a surrogate decision maker, we recommend the creation of a complex discharge committee within the organization so that ethics consultants can properly discharge their duties to assist patients who are unable to advocate for themselves through a fair and transparent process. (shrink)

Objectives: To explore mental health service users’ views of existing and proposed compulsory powers.Design: A qualitative study employing in-depth interviews. Participants were asked to respond to hypothetical questions regarding the application of compulsory powers under the Mental Health Act 1983 for people other than themselves.Setting: Community setting in Southeast England.Participants: Mental health service users subject to Supervised Discharge/Guardianship.Results: Participants considered that the use of compulsory powers was justified if there were some ultimate benefit, and if there was evidence of (...) mental health problems, dangerousness, or a lack of insight. However, participants rejected intrusions into their autonomy and privacy.Conclusions: This paper’s participants indicated that the proposed CTO may be unacceptable because it would threaten service users’ autonomy. Service users’ acceptance of proposed changes is conditional and they emphasised the importance of consent; there is no suggestion that consent will be required for the CTO. The findings also have implications for the exploration of mental health service users’ views and how they might contribute to policy, service planning, and research. (shrink)

Hospitalized patients lacking the mental capacity to consent to treatment may demand to be discharged from the hospital against medical advice. Forced custody of these patients, including the use of restraints, may be required if the plan is to proceed with treatment. This raises ethical concerns with regard to depriving people of their liberty. The determination of the wishes and values of the patient and her best interests may sometimes vary, depending on the assessor or the clinical team entrusted to (...) perform the evaluation. We therefore propose the following triad for clinicians when determining the best interests for this group of patients to ensure ethical and legal soundness as well as in providing consistency in approach. Firstly, the treatment should serve as a rescue response. Secondly, any restraint deployed must be proportionate with a foreseeable end. Her liberty and autonomy interests should be enhanced by the treatment. Thirdly, the patient’s family must be supportive. This paper analyzes the use of the triad approach on two clinical cases, both assessed as lacking in mental capacity to decide on treatment and insisting to be discharged. Using this approach, we could justify how the contrasting outcomes, one in which the voluntary discharge was acquiesced versus the other, which was not acquiesced, were reached. We also examine the compatibility of the triad approach with the obligations under the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD). (shrink)

Increasing prevalence of depression poses a huge challenge to the healthcare systems, and the success rates of current standard therapies are limited. While 30% of treated patients do not experience a full remission after treatment, more than 75% of patients suffer from recurrent depressive episodes. Eye Movement Desensitization and Reprocessing therapy represents an emerging treatment option of depression, and preliminary studies show promising effects with a probably higher remission rate when compared to control-therapies such as cognitive behavioral therapy. In the (...) present study, 49 patients with severe depression were treated with an integrated systemic treatment approach including EMDR therapy that followed a specific protocol with a treatment algorithm for depression in a naturalistic hospital setting. Following their discharge from the hospital, the patients were followed up by a structured telephone interview after 3 and 12 months. 27 of the 49 patients fulfilled the Beck’s depression criteria of a full remission when they were discharged. At the follow-up interview, 12 months after discharge, 7 of the 27 patients reported a relapse, while the remaining 20 patients had stayed relapse-free. The findings of our observational study confirm reports of earlier studies in patients with depression, showing that EMDR therapy leads to a high rate of remission, and is associated with a decreased number of relapses. Patients with depression receiving EMDR treatment may be more resilient to stressors. (shrink)

Although advance care planning can lead to more patient-centered care, the communication around it can be challenging in acute care hospitals, where saving a life or shortening hospitalization is important priorities. Our qualitative study in an acute care hospital in Japan revealed when specifically physicians and nurses start communication to facilitate ACP. Seven physicians and 19 nurses responded to an interview request, explaining when ACP communication was initiated with 32 patients aged 65 or older. Our qualitative approach employed descriptive (...) analysis to identify major themes, which included “initiation by patients” and “initiation by healthcare professionals.” In the latter case, seven specific triggers were identified: when the patients’ medical condition changed in terms of symptom relief, when the patients’ medical condition changed in terms of prognostic prediction, when serious events occurred, when a choice of treatment was presented, when the location for end-of-life care was chosen, when the patients’ cognitive function deteriorated, and when serious events settled down. Within this group of healthcare professionals, physicians were more focused on changes in their patients’ medical condition, whereas nurses focused more on their patients’ desire for a long-term perspective. Nurses encouraged patients to consider ACP themselves, which developed into an approach to respect patients’ autonomy. In acute care hospitals, it appeared to be desirable to have an early discussion where patients could understand the significance ACP, which would matter even after their discharge from the hospital. (shrink)

Why mediation? -- What makes bioethics mediation unique? -- Before you begin a bioethics mediation program -- The stages of bioethics mediation -- Techniques for mediating bioethics disputes -- How to write a bioethics mediation chart note -- Mediation with a competent patient : Mr. Samuels's case -- Mediation with a dysfunctional family : Mrs. Bates's case -- A complex mediation with a large and involved family : Mrs. Leonari's case -- Discharge planning for a dying patient : (...) a role-play -- An at-risk pregnancy : a role-play -- HIV and postsurgical complications in the ICU : a role-play -- Treating the dying adolescent : a role-play -- She didn't mean it : a role-play -- Don't tell mama : a role-play -- An at-risk pregnancy : a role-play transcript -- HIV and postsurgical complications in the ICU : a role-play transcript -- She didn't mean it: a role-play transcript -- Don't tell mama : a role-play transcript. (shrink)

The debate about health insurance coverage and the related issue of unequal access to health care turn on fundamental questions of justice, but for an individual patient like DM, the abstract question about who is deserving of health insurance becomes a very concrete problem that has a profound impact on care and livelihood. DM's circumstances left him stuck in the hospital. A satisfactory discharge plan remained elusive; his insurance coverage severely limited the number and type of facilities that would (...) accept him; and his inadequate engagement in his own rehabilitation process limited discharge options even further. Despite extensive involvement with the psychiatry, social work, physical therapy, and occupational therapy teams, DM consistently made “bad” decisions. He repeatedly refused antibiotics and did not consistently work with rehab services to improve his strength and mobility. Although the clinicians wanted to provide him with the best care possible, he often seemed unwilling to do the things necessary to achieve this care—or perhaps his depression rendered him unable to do so. He also tended to take out his frustration on staff members caring for him. All of this was, in turn, very frustrating for the staff. It may be easy, however, to make too much of DM's role, to see his choices as more important than his circumstances. A major goal of the ethics consultants was to reframe DM's predicament for the staff members involved in his care. (shrink)

Multiple studies have been performed to identify the most common ethical dilemmas encountered by ethics consultation services. However, limited data exists comparing the content of ethics consultations requested by specific hospital specialties. It remains unclear whether the scope of ethical dilemmas prompting an ethics consultation differ between specialties and if there are types of ethics consultations that are more or less frequently called based on the specialty initiating the ethics consult. This study retrospectively assessed the incidence and content of ethics (...) consultations called by surgical vs. non-surgical specialties between January 1, 2013 to December 31, 2018 using our RedCap Database and information collected through the EMR via our Clinical and Translational Science Center. 548 total ethics consultations were analyzed. Our results demonstrate that more surgical consults originated from the ICU, as opposed to lower acuity units, and surgical patients were more likely to have a DNR in place. Surgical specialties were more likely to call about issues relating to withholding/withdrawing life-sustaining treatment, while non-surgical specialties were more likely to call about issues related to discharge planning. There appear to be morally relevant differences between consults classified as the “same” that are not entirely captured by the usual ethics consultations classification system. In conclusion, this study highlights the unique ethical issues experienced by surgical vs. non-surgical specialties. Ultimately, our data can help ethics consultation services determine how best to educate various hospital specialties to approach ethical issues commonly experienced within their field. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Working with Patience:An Insight into Dealing with Difficult EmotionsDavid VilanovaAs the most trusted professionals in the nation, nurses are expected to care for their patients with empathy and freedom from bias. The reality is that nurses are human, and some form of implicit bias is inevitable. In my own experience, this issue has reared its head on several occasions. My nursing background is prominently in cardiac and intensive care. (...) Seeing patients at their most vulnerable has become a regular part of my practice. Among some of the most challenging cases for me have been when I assume care of a patient withdrawing from alcohol. As an adult child with close alcoholic family members, many instances of abuse and pain stick with me today and these are brought to the surface when I care for patients with alcohol use disorder. In most cases, I easily find a healthy balance between remaining an understanding-and-empathetic provider and protecting my emotional and mental health as I navigate ethical and moral issues. However, with this patient population, walking that fine line is especially challenging. How do I navigate and manage intensely personal emotions and biases while providing the high-quality care I vowed to deliver regardless of my patient's life choices, addictions, and illnesses? How do I maintain an appropriate level of neutrality and clarity as this patient's behavior and attitude spark emotional triggers? In other words, how do I take care of someone I don't like?Mrs. H was a middle-aged Hispanic woman, barely coherent, but speaking clearly enough that I could understand her slurred speech. Immediate dread washed over me as I realized my assignment included a patient withdrawing from alcohol. The patient's affect, incoherence, and aggression were all too reminiscent of a traumatic past I still work to heal from. My coworkers couldn't understand her insults and obscenities and were therefore unphased except for noting her unruly and erratic behavior. On the other hand, I could understand much of what she was yelling at me and any other staff who bravely walked into her room. My immediate thoughts were that this woman clearly did not want our help. My every attempt to enter her room, speak with her, and provide care were met with an all too familiar rejection and denial that she even had a problem. Yet here she was in a hospital room, and I was her nurse. She verbalized denial of drinking too much when told that she was being treated for alcohol withdrawal. She stated this denial more to herself than to the health care providers in the room, and it was reminiscent of the denial I have seen in my loved ones. This was ironic, I always thought, as the need for such self-deception in and of itself points to the fact that something may be wrong and worth addressing.But denial or not, today, this patient—Mrs. H, was entrusted into my care. She refused treatments and medications, and this put me in a complex ethical predicament—treating a patient that I do not like for the personal issues she reminds me of, and the treatment of a patient against their refusal, as she was deemed incapable of making her own decisions. The latter of these two issues was easiest to put aside. Legally, this patient needed to be treated through her alcohol withdrawal. Once her mental status cleared up, she could sign out against medical advice or choose to remain until a safe discharge plan was in place. There was a protocol and legal guidelines for this situation. However, no guidelines [End Page 10] truly exist when it comes to the management of a patient that you simply do not like. The result can be a near-instantaneous dread each time you must answer that patient's bed alarm, call light, or most basic needs. A negative bias takes over, and it would be an understatement to say that this affects the quality of care. Patients in situations like this—with providers who judge them as I have been guilty of—can easily become subject to derogatory remarks, health inequities, and biased labeling... (shrink)

BackgroundHospitalized older adults frequently have impaired cognition and must rely on surrogates to make major medical decisions. Ethical standards for surrogate decision making are well delineated, but little is known about what factors surrogates actually consider when making decisions.ObjectivesTo determine factors surrogate decision makers consider when making major medical decisions for hospitalized older adults, and whether or not they adhere to established ethical standards.DesignSemi-structured interview study of the experience and process of decision making.SettingA public safety-net hospital and a tertiary referral (...) hospital in a large city in the Midwest United States.ParticipantsThe study included 35 surrogates with a recent decision-making experience for an inpatient aged 65 or older.MeasurementsThe key factors that surrogates considered when making decisions. Interview transcripts were coded and analyzed using the grounded theory method of qualitative analysis.ResultsSurrogates considered patient-centered factors and surrogate-centered factors. Patient-centered factors included: respecting the patient’s input, using past knowledge of the patient to infer the patient’s wishes, and consider ing what is in the patient’s best interests. Some surrogates expressed a desire for more information about the patient’s prior wishes. Surrogate-centered factors included: surrogate’s wishes as a guide, surrogate’s religious beliefs and/or spirituality, surrogate’s interests, and family consensus.ConclusionOur study indicates that surrogate decision making is more complex than the standard ethical models, which are limited to considerations of the patient’s autonomy and beneficence. Because surrogates also imagine what they would want under the circumstances and consider their own needs and preferences, models of surrogate decision making must account for these additional considerations. Surrogates’ desire for more information about patients’ preferences suggests a need for greater advance care planning. (shrink)

Ms. X is a person with cerebral palsy and schizophrenia. She has intractable bedsores that are a result of her immobility and to poor wound care related to her delusional thinking. Despite intensive community support, the wounds have worsened to the point that she has needed multiple hospitalizations to prevent systemic sepsis, a life‐threatening condition. She is capable of placement decisions and wishes for independence at home but is incapable of making wound care decisions and does not appreciate that immediately (...) returning home from the hospital, instead of going into a special care facility, would likely result in sepsis. The resulting dilemma about discharge planning highlights the complexity involved in weighing concerns around mental illness and capacity for treatment and placement of care. The extent of the care that is required and available in a community or health care system and the slow but relatively certain progression of the symptoms also make the decision challenging. Two commentaries take very different approaches in exploring the question whether Ms. X should be supported to go home or to a special care facility. (shrink)

Background: Determination of the factors affecting missed nursing care and the impact of ethical leadership is important in improving the quality of care. Aim: This study aims to determine the missed nursing care and its relationship with perceived ethical leadership. Research design: A cross-sectional study. Participants and research context: The sample consisted of 233 nurses, of whom 92.7% were staff nurses and 7.3% were charge nurses, who work in three different hospitals in Turkey. The study data were collected using a (...) personal and professional characteristics data form, the Missed Nursing Care Survey, and the Ethical Leadership Scale. Ethical considerations: The study was approved by the non-interventional ethics committee of Dokuz Eylül University Ethics Committee for Noninvasive Clinical Studies. All participants’ written and verbal consents were obtained. Findings: The most missed nursing care practices were ambulation, attending interdisciplinary care conferences, and discharge planning. According to the logistic regression analysis, sex, the number of patients that the nurse is in charge of giving care, the number of patients discharged in the last shift, and satisfaction with the team were determined as factors affecting missed care. No significant relationship was found between ethical leadership and missed nursing care (p > 0.05), and a weak but significant relationship was found between the clarification of duties/roles subscale and missed nursing care (r = −0.136, p < 0.05). Discussion: Ethical leaders should collaborate with policy-makers at an institutional level to particularly achieve teamwork that is effective in the provision of care, to control missed basic nursing care, and to organize working hours and at the country level to determine roles and to increase the workforce. Conclusion: The results of this study contribute to the international literature on the most common type of missed nursing care, its reasons, and the relationship between the missed care and ethical leadership in a different cultural context. (shrink)

One hundred inpatients on an acute hospital elderly care unit and 43 of their relatives were interviewed shortly before hospital discharge. Eighty per cent of elderly patients and their relatives were aware of cardiopulmonary resuscitation (CPR). Television drama was their main source of information. Patients and relatives overestimated the effectiveness of CPR. Eighty-six per cent of patients were willing to be routinely consulted by doctors about their own CPR status, but relatives were less enthusiastic about routine consultation. Patients' and (...) relatives' views about the appropriateness of CPR did not differ significantly. Seventeen percent of patients did not desire CPR. However, 64 per cent of patients were ultimately willing to follow their doctor's advice about the appropriateness of CPR. The conclusion reached is that mentally competent, elderly patients but not their relatives should be routinely consulted about their own desire for CPR in order to avoid resuscitating patients against their wishes. Further research is required to find out how patients would feel about resuscitation if they were terminally ill or chronically confused, and how carers would feel about resuscitating such patients. (shrink)

Estimation of discharge flowing through rivers is an important aspect of water resource planning and management. The most common way to address this concern is to develop stage-discharge relationships at various river sections. Various computational techniques have been applied to develop discharge ratings and improve the accuracy of estimated discharges. In this regard, the present study explores the application of the novel hybrid multigene genetic programming-generalized reduced gradient technique for estimating river discharges for steady as well (...) as unsteady flows. It also compares the MGGP-GRG performance with those of the commonly used optimization techniques. As a result, the rating curves of eight different rivers were developed using the conventional method, evolutionary algorithm, the modified honey bee mating optimization algorithm, artificial neural network, MGGP, and the hybrid MGGP-GRG technique. The comparison was conducted on the basis of several widely used performance evaluation criteria. It was observed that no model outperformed others for all datasets and metrics considered, which demonstrates that the best method may be different from one case to another one. Nevertheless, the ranking analysis indicates that the hybrid MGGP-GRG model overall performs the best in developing stage-discharge relationships for both single-value and loop rating curves. For instance, the hybrid MGGP-GRG technique improved sum of square of errors obtained by the conventional method between 4.5% and 99% for six out of eight datasets. Furthermore, EA, the MHBMO algorithm, and artificial intelligence models performed satisfactorily in some of the cases, while the idea of combining MGGP with GRG reveals that this hybrid method improved the performance of MGGP in this specific application. Unlike the black box nature of ANN, MGGP offers explicit equations for stream rating curves, which may be counted as one of the advantages of this AI model. (shrink)

A request to admit a hospital inpatient with motor neurone disease to the hospice generated unusual unease. Significantly, withdrawal of ventilation had already been planned. The presumption that ventilation would be withdrawn after transfer presented a dilemma. Should the hospice accept the admission? If so, should the hospice staff stop the ventilation, and then when and how? Debate centred on the continuity of best interests and the logistics of withdrawing ventilation. The factors making the request contentious identified competing interests (...) within hospice admission decision making that could detrimentally impact on patient care. (shrink)

Objectives: To investigate whether different methods of obtaining informed consent affected recruitment to a study of delirium in older, medically ill hospital inpatients.Design: Open randomised study.Setting: Acute medical service for older people in an inner city teaching hospital.Participants: Patients 70 years or older admitted to the unit within three days of hospital admission randomised into two groups.Intervention: Attempted recruitment of subjects to a study of the natural history of delirium. This was done by either a formal test of capacity, followed (...) by either a request for consent or an attempt at obtaining assent from a proxy, or a combined informal capacity/consent process.Main outcome measures: Prevalence and severity of delirium, and, as case mix measures, length of hospital stay and destination on discharge.Results: Recruitment of subjects through establishing formal capacity and then informed consent was less successful and, compared with those recruited through the usual combined capacity/consent approach, yielded a sample with less cognitive impairment, lower severity of delirium, lower probability of case note diagnosis of delirium and lower rate of entering a care home.Conclusions: Methods of obtaining informed consent may significantly influence the case mix of subjects recruited to a study of delirium. Stringent testing of capacity may exclude patients with delirium from studies, thus rendering findings less generalisable. A different method is necessary to achieve an ethical balance between respecting autonomy through obtaining adequate informed consent and avoiding sample bias. (shrink)

Studies link involuntary outpatient commitment with improved patient outcomes, fueling debate on its ethical justification. This study compares inpatient utilization for committed outpatients in the 1990s with those who were not under outpatient civil commitment orders. Findings reveal committed outpatients had higher utilization of inpatient services and restraint episodes prior to their commitment compared with a control group. Committed outpatients also were more likely to have been on discharge status at the time of admission, have been admitted (...) involuntarily under emergency legal procedures, and have had a greater number of admissions and hospital days prior to their commitment. Following commitment, patients had fewer hospitalizations, shorter lengths of stay, fewer seclusion episodes and hours, and fewer restraint episodes and hours. Findings are discussed within the context of parens patriae and therapeutic jurisprudence, and support medical and public policy justifications for ethical uses of outpatient civil commitment laws for seriously mentally ill patients. (shrink)

Studies link involuntary outpatient commitment with improved patient outcomes, fueling debate on its ethical justification. This study compares inpatient utilization for committed outpatients in the 1990s with those who were not under outpatient civil commitment orders. Findings reveal committed outpatients had higher utilization of inpatient services and restraint episodes prior to their commitment compared with a control group. Committed outpatients also were more likely to have been on discharge status at the time of admission, have been admitted (...) involuntarily under emergency legal procedures, and have had a greater number of admissions and hospital days prior to their commitment. Following commitment, patients had fewer hospitalizations, shorter lengths of stay, fewer seclusion episodes and hours, and fewer restraint episodes and hours. Findings are discussed within the context of parens patriae and therapeutic jurisprudence, and support medical and public policy justifications for ethical uses of outpatient civil commitment laws for seriously mentally ill patients. (shrink)

ObjectiveThe aim of this study was to test the feasibility of telepsychology support for patients with severe cardiorespiratory disease and their caregivers. A secondary objective was to explore pre-post relationships between patients' and caregivers' clinical measures.MethodsA telehealth program incorporating telepsychology support, i.e., an “on-demand” phone service with a psychologist, was provided to consecutive cardiorespiratory patients at discharge from inpatient rehabilitation and to their caregivers. At the start and end of the 1-year program, participants were interviewed “face-to-face,” and their (...) anxiety/depression level, patients' quality of life, and caregivers' family strain and needs were assessed: we analyzed the correlations and evaluated customer satisfaction.ResultsOf 80 eligible individuals, 40 took part in this study: 22 patients and 18 caregivers. Eleven requested tele-psychological support, resulting in 51 consultations focused on anxiety, difficulty in patient management, worry about the patient's emotional state, and need for emotional support; 3 participants underwent a tailored psychotherapy program. All participants expressed high satisfaction with the service. At enrolment, anxiety was less evident in patients than in caregivers, while depressive symptoms were more evident, and correlated with MRF-28 and MQOL. Caregivers' FSQ showed a “strongly recommended” need for support; at enrolment, high levels of anxiety/depression were correlated with high FSQ ; depressive symptoms correlated negatively with age and positively with emotional needs ; anxiety was positively correlated with education level. At follow-up, patients' perception of support tended to increase, while caregivers' strain tended to decline. At enrolment, caregivers' anxiety/depression and strain correlated with patients' quality of life. At follow-up, caregivers' strain correlated with patients' quality of life and cognitive performance.ConclusionTelepsychology support associated with a telehealth service is feasible and satisfying for both participants and psychological management. A suitable support program can benefit both patients and caregivers, particularly those at higher risk of depressive symptoms and anxiety. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Carmen MirandaJessica LesCarmen Miranda, she called herself today. She suffered from decades of schizoaffective disorder and now more recently, end–stage renal disease from uncontrolled diabetes. I first met Carmen two weeks prior when she had been brought to the hospital on a 72 hour psychiatric hold for self–harm. She failed to go to dialysis for a week, an act that would kill her if allowed to continue. Now she (...) was here again, for the same reason.Everyone of competent mind has the right to refuse medical treatment. Unfortunately, Carmen’s mind was not currently grounded in reality. So against her will, our family medicine team admitted her to the hospital and arranged for dialysis early the next morning. None of us liked doing this. Fortunately, when the time came for the dialysis tech to insert the dialysis catheter into her shunt, Carmen agreed peacefully. After her dialysis, we had no right to keep her in the hospital because her life was no longer in danger, at least until the next week. We discharged her to home. However the question remained, what about next time?To navigate this ethical gray zone, we called an ethics committee meeting. An ethicist, nurses, hospital social workers, the inpatient family medicine resident team, and most importantly, two people who knew her very well—her caseworker and long–term psychiatrist—discussed her case for an [End Page 103] hour. Our medicine team learned that in her last period of clarity two months prior, Carmen made contradictory statements regarding her wishes. Carmen told her caseworker she was tired of dialysis and being sick and stated it was time to let herself go. During the same lucid week she told her psychiatrist that she was grateful she had been forced to complete dialysis against her wishes after a run of non–adherence while suffering psychosis a couple of months prior. Now months later she was in a downward spiral, exacerbated by the deterioration of her mentally ill husband. If she missed a dialysis treatment here and there, it was okay, but when she went on a run missing several treatments, it was slow suicide.The ethics meeting concluded that Carmen needed to complete an advanced directive and select a power of attorney other than her gravely incompetent husband as soon as she was deemed competent. If she did not become lucid again, her psychiatric team should apply for conservatorship, a legally appointed person who serves as guardian for a gravely disabled mentally ill person. However, conservatorship would take months. In the interim, the ethics committee ruled that our medicine team would continue to provide lifesaving treatment for her, against her wishes if necessary.The ethics meeting adjourned but our medicine team remained in a gray area. To what length should we go to treat her? If she continued to refuse dialysis would we hold her in the hospital until she became sufficiently docile by inevitable uremia that we could peacefully dialyze her? Possibly. Would we go so far as to put her under anesthesia to complete her dialysis? Personally, I hoped not.Just three days after the ethics committee meeting, her caseworker found Carmen yelling nonsensical phrases through the front door of her home while her husband held the door shut with his beer belly and good shoulder. After gaining entry later in the day, Carmen’s caseworker found their mutual medication collection strewn in the bathtub and no food in the house. He placed Carmen on a psychiatric hold and transported her to the hospital. The emergency department paged me when Carmen arrived. I braced myself for the possibilities that lay ahead. When I reached Carmen, she was sitting in a room reserved for psychiatric patients and under watch by a friendly police officer accustomed to these situations.“Hi, Carmen,” I said, one step into her room. She sat on the edge of the gurney, wrapped in three blankets.“Cold,” she said.The police officer spoke from behind my shoulder, “She has been requesting cup after cup of ice water, she won’t take anything else.”“Let’s get you more comfortable.” I returned with a warm blanket and draped it over her... (shrink)

This study appeared in full in the last issue of Research Ethics Review (2008; 4 (2): 68). MJ's research focuses on those patients with brain damage following trauma such as a road traffic accident. She wants to find out about their experiences of daily life once they have been discharged from hospital. She plans to use a phenomenological approach in which each participant will be asked to take part in a series of in-depth interviews, via email, over a period of (...) about two years. These interviews will allow her to compare participants' experiences in different parts of the UK. MJ has a research partner in Auckland; the two of them are planning a similar series of interviews in New Zealand to allow for comparison between participants' experiences in the two countries. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Clinical CommentaryChua Hong Choon, Adjunct Associate ProfessorThe case for commentary describes a difficult, and yet not uncommon, clinical situation faced by clinicians at the Institute of Mental Health (IMH) in the course of their work. Based on the information provided on the case, the patient is likely to be suffering from the paranoid subtype of schizophrenia, and his illness is characterised by hostile and aggressive behaviour during episodes of (...) relapse.Although aggressive behaviour is known to be associated with young, male patients with paranoid delusions, auditory hallucinations and lack of insight,1 it is still necessary to exclude other causes of aggressive behaviour in this young man. Two causes of aggressive behaviour that are sometimes misattributed to schizophrenia are antisocial personality disorder and substance abuse. However, Mr. T did not have a history of conduct or behavioural problems prior to the onset of his psychotic illness, and he was also not reported to be violent or disruptive during the periods when he was on regular medication. There was also no history of illicit drug use.The initial onset of Mr. T’s illness while he was serving his National Service is a fairly common presentation of the first episode of schizophrenia in Singaporean males. While traits apparent prior to National Service such as his academic difficulties and inability to make friends are associated with the development of schizophrenia,2 the stress of regimented life and military drills might be more closely associated with his initial full-blown psychotic episode with prominent paranoid (and persecutory) delusions.The systematised nature of Mr. T’s delusions and the prominent threatening auditory hallucinations significantly increase his risk of [End Page 217] dangerousness,3 and when his wife became “incorporated” into his delusional beliefs, he began to threaten her physically during episodes of relapse. Despite being only 28 years old, Mr. T has already been hospitalised numerous times for inpatient treatment, due to frequent relapses of his illness. While relapses in schizophrenia may be attributed to various factors, including lack of social support, substance abuse, poor (or partial) response to medication and psychosocial stressors, Mr. T’s multiple relapses were primarily due to the stopping of his medication and his refusal to continue with any form of psychiatric treatment.The key problem to be addressed in this case is therefore the patient’s severe lack of insight which leads to recurrent episodes of treatment non-adherence and subsequent relapses.Mr. T’s wife has come to the clinic to ask for medication to secretly put into his food. Although the patient is apparently in remission of his condition (having just been treated and discharged from hospital), he has again stopped his medication, and she is justifiably afraid that he will become unwell again. Recognising that the patient’s lack of insight is the main (and possibly only) reason for his refusal to take medication, it would be prudent to first consider if all possible actions had been taken to create an awareness and to help the patient gain insight into his illness and the need to take medication. This may yet be possible in the window of opportunity that exists when the patient is in remission of his illness (and is therefore not disturbed by the symptoms of his psychotic disorder).Recent studies have demonstrated that psycho-education is able to reduce self-stigmatisation in individuals with schizophrenia, and also significantly improve insight 4 (as measured by the Birchwood’s Psychosis Insight Scale). A 2011 Cochrane Review 5 also concluded psycho-education does seem to reduce relapse, readmission and encourage medication compliance, as well as reduce the length of hospital stays in patients with schizophrenia. In this case, psycho-education could be given to Mr. T even after he has been discharged from hospital; he might not want to continue with medication, but he might consider seeing a trained clinician (case manager, nurse or medical social worker) to make sense of his life experiences. Engaging Mr. T through psycho-education may result in sufficient insight for him to consider resuming medication voluntarily, at least in the short term.Although there is a paucity of studies examining specific psycho-therapies (including cognitive behavioural therapy... (shrink)

Background: Professional nurses provide holistic healthcare to people and deal with patients closely. Furthermore, patients need nurses to do self-care and patients trust them for their treatments. Therefore, trust is extremely important in a professional care relationship and in satisfactory patient outcomes. Objective: The aim of this study was to examine the patients’ views on the trust status toward nurses and the factors important for the development of trust in a nurse–patient relationship. Research design: This research was planned as a (...) descriptive cross-sectional study. Participants and research context: The study was carried out between April and July 2014 at the oncology hospital of a university in Ankara, Turkey. The sample size was calculated by power analysis and was composed of 356 inpatients diagnosed with cancer. For data collection, a questionnaire and the “Trust in Nurses Scale” were used. From the hospital and written informed consent obtained from participating patients: Approval from the University Clinical Research Ethics Committee was obtained. Written approval was obtained from the hospital and consent letter from the patients. Findings: The average score on the scale was 24.5 ± 3.9, meaning that patients had a high level of trust toward nurses in this hospital. The patients who were in the 50–59 age group and men had statistically higher scores compared with other groups. Patients’ answers revealed that themes of “Personal and Professional Characteristics” were important when developing trust, however “Mistreatment, Professional Incapability, and Communication Problem” were important causing mistrust toward the nurses. Conclusion: In this study, the nurses’ professional competencies and interpersonal caring attributes emerged as most important in developing trust. This study paid attention to the values and attitudes that develop patients’ trust toward nurses. Moreover, the findings raise ethical questions about how the patients’ basic rights are to be protected and how their trust level can be heightened. Nurse managers need to assess continuously how trust toward nurses is developed, protected, and maintained in their institutions. (shrink)

The present war in Ukraine has seen millions of women flee as refugees, while martial law forbids adult men under 60 from leaving the country. According to various reports, many and perhaps most women Ukrainian refugees are breaking romantic ties with the men they leave behind, building new lives with men in their countries of refuge, and/or planning never to return. I avoid any comment about the morality of these events, and instead take up the general question of whether (...) women war refugees have any obligations of “connubial loyalty” to their menfolk in circumstances where those men are discharging a moral obligation to fight in the war that precipitated their womenfolk’s flight in the first place. I answer that they do. (shrink)