Jon Ennis

Stopping Life-Sustaining Medical Treatment: Psychiatric Considerations in the Termination of Renal Dialysis

Data are presented regarding the decision by medical staff and by patients to discontinue renal dialysis. Some relevant issues regarding the patients are discussed, including their mental competence, underlying motivation and psychiatric state. Also some of the medical factors involved in the decision to stop treatment are considered. Emphasis is placed on the importance of the patients sense of active participation and involvement in his treatment. Mention is made of the importance of interventions to decrease the psychological morbidity in survivors of patients who stop dialysis.

Standards and guidelines for the psychotherapies

Standards and Guidelines for the Psychotherapies provides a comprehensive overview of the art and science of psychotherapy and a set of practice guidelines for psychiatrists. The main aim is to improve standards and practices, and to initiate discussion. This book was developed from a report by the Joint Task Force on Standards and Guidelines for Medical (Psychiatric) Psychotherapy, which was established by the Ontario Psychiatric Association and Ontario Medical Association (Section of Psychiatry). The report was prepared in response to four phenomena emerging in recent psychotherapy: 1) The realization that there were no written guidelines or standards for the practice of medical psychotherapy; 2) the changing forces that now influence health policy and funding, both in U.S. and Canada; 3) The potential for arbitrary deinsurance of some procedures in the absence of agreed upon standards, and without regard to the evidence for the effectiveness of psychiatric procedures; and 4) Growing concern regarding the problem of sexual abuse of patients by physicians. This is an excellent reference book for medical professionals practicing in the field of psychotherapy, and will prove to be a valuable resource in the ongoing practice and development of psychotherapy.

Management of the repeatedly suicidal patient

Although repetitive suicidal behaviour is commonly encountered, a relatively small number of very difficult patients engage in it. These individuals suffer primarily from severe personality disorders, as well as alcoholism and drug abuse. They are at high risk for eventual suicide. Although as a group they receive a great deal of hospital treatment, inpatient management is fraught with difficulties. Extended inpatient treatment is unlikely to be of benefit and may perpetuate the behaviour by leading to regression and excessive dependence on hospitalization. A model of management is described which couples the use of a brief-stay, crisis, inpatient unit and community-based outpatient treatment. Communication between institutions and agencies involved in the patients care as well as coordination of services is essential. Acceptance by therapists of the risk of suicide and the realistic limitations to meeting these patients’ needs can help such patients assume more responsibility and independence.