The patient’s autonomy: a guiding principle.
This article is an additional commentary on the article, "Treatment Over Objection: Ethical and Legal Principles."
A key function of consultation-liaison (C-L) psychiatrists is to work along with their nonpsychiatry colleagues to ethically manage patients with complex diagnoses in the hospital. As Gwendolyn Cody, MD, notes, “Mr Reese” was admitted as he was experiencing psychosis and serious illness. His refusal of treatment posed a clear risk to his survival and appeared to derive from his psychiatric illness. Although the principles of medical ethics are consistent in all settings, the laws governing treatment over objection (TOO) vary depending on whether the patient has been medically or psychiatrically hospitalized. Laws also vary by state, thus the decision to treat a patient over objection may not apply to patients in all states.
What helped Mr Reese’s medical team cope with his rejection of treatment, and maladaptive denial of his illnesses,1 was the consistent presence of the C-L psychiatry team. The patient’s autonomy was held as a guiding principle; however, there was an empathic approach to both his medical and psychiatric needs, and the distress of his medical team in not being able to properly care for him therapeutically.
As noted by George Henry in 1929, “On the staff of every general hospital there should be a psychiatrist who would make regular visits to the wards,…direct a psychiatric outpatient clinic,…continue the instruction and organize the psychiatric work of interns and…attend staff conferences so that there might be a mutual exchange of medical experience and a frank discussion of the more complicated cases.”2
The first formal C-L division in a general hospital was started by Edward G. Billings, MD, in Colorado in 1934. Following the principles outlined by Billings,3,4 C-L services now provide integrated care of patients with complex diagnoses in hundreds of hospitals. In the case presented here, the consideration of TOO was an option if Mr Reese could not accept necessary treatment; however, the work of the psychiatrist with the patient and the medical team allowed him to permit treatment and be safely discharged.
Dr Muskin is a professor of psychiatry and senior consultant in C-L psychiatry at Columbia University Irving Medical Center in New York, New York. He is also a member of the Psychiatric Times Editorial Board.
1. Strauss DH, Spitzer RL, Muskin PR. Maladaptive denial of physical illness: a proposal for DSM-IV. Am J Psychiatry. 1990;147(9):1168-1172.
2. Henry GW. Some modern aspects of psychiatry in a general hospital practice. Am J Insanity. 1929;86(3):481-499.
3. Billings EG. Teaching psychiatry in the medical school general hospital: a practical plan. JAMA. 1936;107(9):635-639.
4. Billings EG. The psychiatric liaison department of the University of Colorado Medical School and hospitals. Am J Psychiatry. 1966;122(12):28-33.