Harold I. Schwartz

Life‐Sustaining Treatment and Assisted Death Choices in Depressed Older Patients

OBJECTIVES: The major purpose of this study was to examine the effect of depressed mood in older, medically ill, hospitalized patients on their preferences regarding life‐sustaining treatments, physician‐assisted suicide (PAS), and euthanasia and to determine the degree to which financial constraints affected their choices.

Inpatient psychiatric care in the 21st century: the need for reform.

Driven by financial pressures, the sole focus of psychiatric inpatient treatment has become safety and crisis stabilization. Data are lacking on outcomes of ultrashort-stay hospitalizations; however, such stays may diminish opportunities for a sustained recovery. In the absence of an evidence base to guide clinicians and policy makers, mental health professionals have an ethical obligation to promote what they consider to be best practice. This Open Forum focuses on the need to reconsider the current model of inpatient hospitalization in order to maximize positive outcomes and emphasize appropriate transition to the community and less intensive levels of care. A model of care is presented based on rapid formulation of diagnosis, goals, and treatment modalities before treatment begins. Three phases are described--assessment, implementation, and resolution--with specific principles to guide length-of-stay decisions and requirements for staffing.

Instability of attitudes about euthanasia and physician assisted suicide in depressed older hospitalized patients

The objective of this study was to examine the interest of non-terminally ill hospitalized elderly patients in euthanasia and physician assisted suicide (PAS) and to determine the stability of these interests over time. Patients age 60 or older (n=158), including both a depressed sample and non-depressed control sample, underwent a structured interview evaluating their interest in euthanasia and PAS in the event of a series of hypothetical outcome scenarios. Substantial proportions of subjects (varying from 13.3%-42% depending on the scenario) expressed hypothetical acceptance of euthanasia and PAS. After six months a subset of patients changed their minds about euthanasia and PAS (8% - 26% depending on the scenario), most often in the direction of initial acceptance to later rejection. Patients depressed in the hospital and interested in PAS for the outcome of their current (non-terminal) condition were significantly more likely express unstable opinions, with most rejecting it six months later. Other correlations of instability, in specific scenarios, included being male, experiencing higher baseline suffering, poorer subjective health and lower instrumental support. Because euthanasia and PAS actions are irreversible, findings of instability have important implications both clinically and for design of PAS legislation.

Determinants of geropsychiatric inpatient length of stay.

Despite efforts to decrease lengths of acute psychiatric hospital stays, some geriatric inpatients continue to have extended stays. This research examined factors related to length of stay (LOS), including legal and administrative factors not traditionally included in prior studies. The charts of 384 patients, representing all 464 discharges from an inpatient geropsychiatric unit over a one-year period, were evaluated retrospectively and analyzed using logistic regression and logarithmic transformation. The LOS of over 12% of the inpatients was 26 days or more (average LOS 14.1). Factors significantly associated with longer LOS were: receiving electroconvulsive therapy (ECT), higher Brief Psychiatric Rating Scale (BPRS) positive symptoms scores, falling, pharmacology complications, multiple prior psychiatric hospitalizations, requiring court proceedings to continue hospitalization or medicate against will, consultation delays and not performing ECT on weekends. Neither demographics nor diagnoses alone had influence on length of stay. Incorporation of LOS predictors into Medicare Inpatient Prospective Payment System (IPPS) would more accurately account for the complexity in the cost of caring for geropsychiatry patients.

Could adequate palliative care obviate assisted suicide

Physician views regarding the relationship between palliative care and physician-assisted suicide (PAS) are poorly understood. This survey of Connecticut physicians (n = 2,805; 40% response rate) found physicians nearly evenly divided on the question of whether there is a role for PAS in systems where adequate palliative care is available (42% no, 41% yes, 17% uncertain). These groups differ significantly on numerous personal and practice characteristics (all p < .001), as well as perceptions of various risks of PAS (p < .001). Written comments by 152 respondents provide further insights. Views on the respective roles of palliative care and PAS are highly discordant, challenging the development of clinical standards for end-of-life care.

A Rating Inventory for Resident Case Presentations

We devised a rating scale, the Resident Case Presentation Inventory (RCPI), to evaluate psychiatry residents’ case presentations at our hospital’s disposition conference. A review of 69 inpatient cases presented prior to discharge revealed that residents’ greatest deficiencies were in the following two areas: 1) knowing indications for specific outpatient treatments and 2) coordinating input from various clinical disciplines, both inpatient and outpatient. The RCPI allows early identification of residents’ educational needs and can give ongoing feedback on their progress.