Frederick H. Lowy

Psychiatric Consultation for Competency to Refuse Medical Treatment: A Retrospective Study of Patient Characteristics and Outcome

Forty-one psychiatric consultations on medical-surgical inpatients for competency to refuse medical treatment were studied retrospectively. The competent (n = 16) and incompetent (n = 25) patients were compared in terms of demographic data, diagnoses, clinical variables, details about treatment refusal, and outcome following competency assessment. The incompetent patients tended to be men, the focus of more urgent requests, and to have refused operations. The incompetent patients tended to have organic brain syndromes; the competent patients had personality disorders, adjustment disorders, or no psychiatric diagnosis. Ultimate acceptance of treatment initially refused was common in both groups; differential psychiatric interventions were recommended. The process of psychiatric consultation appeared to facilitate acceptance of treatment initially refused.

Public Opinion Regarding End of Life Decisions: Influence of Prognosis, Practice and Process

The purpose of this study was to examine the effect of changing key factors in survey questions on public opinion regarding end-of-life decisions. These factors were: (a) patient prognosis (likely vs unlikely to recover from the illness); (b) end-of-life practice (foregoing treatment vs assisted suicide vs euthanasia); and (c) and decision making process (competent patient vs incompetent patient based on living will vs incompetent patient based on family wishes). A representative quota sample of 2019 Canadians 18 years of age or older were surveyed using a 13-item questionnaire with 12 items eliciting attitudes towards end-of-life decisions. The questions were systematically varied according to three key factors; patient prognosis, end-of-life practice and decision making process. One item assessed whether respondents had completed a living will. In the case of a decision to forgo life-sustaining treatment in a competent patient, public approval was 85% if the person was unlikely to recover and 35% if the person was likely to recover. In the case of a competent patient unlikely to recover, public approval was 85% for forgoing life-sustaining treatment, 58% for assisted suicide, and 66% for euthanasia. In the case of forgoing life-sustaining treatment for a patient unlikely to recover, public approval was 85% for a competent patient, 88% for an incompetent patient who had expressed his/her wishes in advance through a living will, and 76% for an incompetent patient based on a familys request. The influence of these key factors was similar in other cases examined. Ten percent of Canadians said they had completed a living will. It was concluded that patient prognosis has a major effect, end-of-life practice a moderate effect, and decision making process a minor effect on public opinion regarding end-of-life decisions.

Management of the Persistent Somatizer

Patients who suffer and complain of symptoms for which no adequate organic pathology is found present serious management problems. Patients who display somatization phenomena are discussed with respect to incidence, psychopathology and predisposing factors—social and cultural, early life experiences, personality characteristics and individual psychodynamics. Although primary prevention of somatization is not yet feasible, early recognition and treatment are possible. The role of the psychiatrist includes: formulation of diagnosis; assessment for therapy; planning of treatment; and, at times, becoming the primary therapist. The family physician has the best opportunity for early detection and prevention of chronicity of somatization phenomena. Pharmacotherapy, behavior modification and some newer approaches in the management of these persistent somatizers are discussed.

The psychiatric training of medical students.

Undergraduate psychiatric education should be concerned mostly with those aspects of psychiatry required for the proper practice of medicine. Psychiatric concepts and techniques are applicable to all medical practice and relevant to the daily work of every physician or surgeon. Therefore, in the psychiatric training of medical students the focus should be primarily on teaching “psychiatry of medical practice” and much less on teaching “specialty psychiatry. “ The teaching of psychiatry for medical practice will be best accomplished by selecting patients who are more like those the student will see later on as a practising physician. A systematic effort should be made to develop joint teaching with other departments, if we are to hope that students will carry over the approach we teach them to other subjects of medicine. Counselling and psychotherapy are essential skills for every physician or surgeon; medical students should be taught these skills by psychiatrists who are not just skilled psychotherapists but are also comfortable in their role as physicians in view of the importance of this role for the development of the identity of the medical student as a physician. The quality of the psychiatric training of medical students is dependent to a large extent on the priority accorded to undergraduate teaching by the department of psychiatry; competing activities, however, can result in undergraduate teaching being given less than top priority. Long-standing difficulties which psychiatry and psychiatrists experience in the medical school may impede undergraduate psychiatric education; these difficulties can be lessened by the closer involvement of psychiatrists with other physicians in the clinical and educational programs.

To be or not to be a psychiatric chief resident. Factors in selection.

The issues involved in selecting a psychiatric chief resident have been examined. Problems associated with this position include poorly defined objectives and role; lack of training for the job; a marginal position at the interface of groups that at times are in conflict, leading to situations of divided loyalties and unrealistic performance expectations. Qualities seen as desirable in a chief resident have been discussed. In addition to the usual personal qualities which command respect these include organizing ability, leadership potential, mediation skills, the capacity for self direction and humour. Factors which make the position attractive and factors relevant to appropriate evaluation are considered. To improve the performance and job satisfaction of chief residents, the following points are suggested: • The expectations related to the position should be clarified in terms of specific objectives when the candidate is selected or elected. • Whom he reports to and whom he works for should be clear. • Before, or soon after, assuming office the chief resident should have exposure to teaching or supervision in group dynamics, consultation skills and mental health administration.

Competency assessments : Perceptions at follow-up

Objectives: To report on the perceptions of assessment of competency and its consequences on a group of clients and significant others at follow-up. Methods: Ninety-five interviews were conducted using a carefully developed semistructured telephone interview of 24 clients and 71 family/caregivers, representing the perceptions of about 80 clients. Results: There was general satisfaction in the competency assessment process. There was a perception that interests and rights were protected. Clients were seen to be less involved in all spheres of decision making rergardless of capacity outcome. Clients and families were satisfied with how decisions were made. Conclusions: Follow-up study of competency assessment does not support the conclusions previously drawn based on court record studies that assessments are deleterious and frequently result in violations of rights.

Overview: Certification Examination: The Canadian Certification Examination in Psychiatry: I: Historical Notes

There has been much criticism of the format and process of the certification examination in psychiatry, and some of this is based on lack of information regarding the history of the specialty certification procedures, the Royal College of Physicians and Surgeons and the Board of Examiners. In this first of three reports the history of the Royal College as the certifying organization is traced, and the relevant College structures are briefly described, including the Specialty Committee on Psychiatry which is instrumental in appointing the clinical examiners. The clinical examiners since 1965 are identified.

Le consentement éclairé: un atout pour la psychothérapie?*

Is it desirable to extend the practice of explicit informed consent to psychotherapy? Is it possible? How? This article offers preliminary answers to these questions following a literature review and reflection on the theory of informed consent and psychotherapy. It explores the advantages and the possibility of using explicit informed consent in place of the implicit consent obtained currently. Explicit consent for psychotherapy would be interactive, iterative, repeated and revocable. It would take into account specific characteristics of psychotherapy, such as the fact that it is a process rather than a procedure, its relative unpredictability, the active part the patient plays in treatment, and the importance of the unconscious, transference and counter-transference. It would have the advantages of respecting the patients’ autonomy without sacrificing their well-being, of having meaning not only for medico-legal protocols but for the patient, and would improve satisfaction with and the efficacy of psychotherapy as a treatment modality. The proposed model provides direction for future research, both empirical and theoretical.

Physician attitudes toward the regulation of fetal tissue therapies: empirical findings and implications for public policy.

he use of aborted fetal tissues in research and therapy (FTT) has raised exciting possibilities T and a host of social, legal and ethical issues. Perhaps the most difficult issue is whether the use of materials from elective abortion can be viewed and weighed separately from the abortion itself, or if in using these tissues there is inherent complicity with the abortion act. Those who oppose F I T claim that there is complicity with the abortion act and liken the use of fetal tissue from abortions to the use of data from the Nazi experiments. Within this lobby are those who claim that the option to donate fetal tissues will make abortion a more attractive alternative for pregnant women, and that there are doctors who will offer fetal tissue donation as a positive incentive to abortion-with the net effect that more abortions will take place. It is also suggested that some women will initiate pregnancies for the sole purpose of undergoing abortion to donate fetal tissue, either for compensation or for donation to a loved one. Finally, this faction argues that donation of tissue from elective abortion will lead invariably to an increased societal acceptance of abortion: one step along the “slippery slope” to the acceptance of practices such as infanticide. This paper reviews the technical rationale for the use of FTT, the core of the ethical debate, current approaches to regulation in various jurisdictions, and, finally, it discusses empirical findings regarding practitioner attitudes towards FTT regulation and their implications for public policy in Canada and elsewhere. Why fetal tissue?

Realities of Drug Use in Society

SummaryThe objective of pharmacotherapy is to restore health or, at least, to limit illness and disability. Drug safety depends upon a strong, reliable chain from the basic science laboratory to the consumer. However, this chain is uneven in strength and the most unpredictable links involve the human factors which contribute substantially to adverse drug reactions. These include misprescribing by physicians, often because of educational deficiencies and sometimes because of the influence of manufacturers’ promotional strategies, as well as noncompliance by consumers.