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Manning the front lines of mental health crises is a demanding and dangerous occupation. However, according to a recent American Psychological Association study, many psychology internships provide limited or no training in emergency psychological services. Emergencies in Mental Health Practice: Evaluation and Management, a book edited by Phillip Kleespies, seeks to fill this need. From determining if a situation is an actual emergency to how to process the outcome, it's all there. It is an excellent resource for anyone involved in emergency mental health, but what is most impressive of the editor is the insight to include issues like the right to die. Mental health professionals have expertise that may be utilized in the full spectrum of emergency patient care, and it is important to be proactive rather than reactive when major shifts in health care policy occur. Being proactive requires being prepared.
Issues in this multi-authored text include how to handle the suicidal or violent patient and how to help victims of violence. Dr. Kleespies does an excellent job of synthesizing the important aspects of emergency care, working from simple questions like "What defines an emergency as opposed to a crisis?" to " How do I manage potentially dangerous situations?" Each section of the book has experts sharing their wealth of experience and knowledge.
In the section "Medical Conditions Presenting as Psychological Crises" there is a general overview of the psychopharmacology of major classes of medications used in psychiatry. With the increasing use of medicines as treatment for mental illness, the psychotherapist needs to keep an updated, working knowledge of current medication options. Just as important is the ability to recognize their potential adverse reactions, some of which may constitute medical or behavioral emergencies. Sufficient information is given for the nonmedical professional, and the section provides an excellent review of antipsychotics, antidepressants, mood stabilizers, and anxiolytics. Also included in these chapters are some of the major medical conditions that may have psychological symptoms, such as Alzheimer's, Parkinson's, temporal lobe epilepsy, and cardiac disease. This section helps the health professional recognize the red flags indicating medical treatment is needed while the emphasis on the biopsychosocial model promotes integration of all aspects of good mental health care.
Another section, "The Impact of Emergency Service on the Clinician", explores an important issue that is not often addressed. Providers not paying attention to their own needs are soon in need of care themselves. By looking at the impact of working in an emergency setting, mental health professionals can construct a strong personal safety net. Care providers must not forget the personal toll paid in dealing with crises and the need to keep healthy in order to perform their jobs well. It is estimated that psychiatrists, on average, will have one patient in active treatment complete suicide during their career. Knowing how to handle the consequences of bad outcomes is invaluable when the inevitable happens.
The most interesting section for me was the book's inclusion of the section, "End of Life Issues." Also thought provoking was the complementary section, "Risk Management in Psychological Emergencies," which focuses on the legal aspects of providing care to suicidal and violent patients. Living in Michigan, one can not avoid the issues highlighted by the actions of Dr. Jack Kevorkian. I have guided patients and their families through the difficult decision of whether or not to withdraw life-sustaining care and have spent sleepless nights ruminating over how one can ever be an expert in this area.
While all situations are different, there are basic principles to be familiar with to provide guidance in what is the ultimate personal decision. It wasn't long ago that the Nancy Beth Cruzan case (1989) concerning the right to refuse life-sustaining treatment was argued before the Supreme Court. Now it is common place to have living wills and legal guardians placed in the position of advocating for loved ones in absentia. This is a time no person should be without proper guidance. We as mental health professionals have an obligation to have expertise in this area and to provide that guidance. End of life issues are real emergencies, especially to those faced with these situations and decisions.
What are the basic principles of end of life issues outlined in Kleespies' book? At the heart of the right to refuse treatment is informed consent, which is composed of three components -- information, voluntariness, and competency. The first component supports the patient's right to adequate information about his or her treatment so that a reasonable decision can be made. The patient is made aware of the risks and benefits of the various treatment options, the risks and benefits of refusing treatment and probable outcomes if known. The next component of informed consent is that it must be voluntary. The circumstances surrounding the consent process must be free of coercion, threats, or fraud, and the patient must not be under duress that is affecting his or her decision-making ability. Finally, there is the issue of competency. It must be noted that competency is a legal term in which a person is competent unless deemed incompetent by the courts. We as mental health professionals merely express our opinions as to competence and functional ability, but the court makes the final decision. According to Roth et al. (1977), there are five categories of tests for competency: (1) evidencing a choice, (2) "reasonable" outcome of choice, (3) choice based on "rational" reasons, (4) ability to understand, and (5) actual understanding. Mental health professionals should be intimately familiar with these principles. Dr. Kevorkian, a pathologist who does not provide patient care, doesn't follow these principles. He seems driven by some motivation other than compassion for the suffering.
The right to refuse life-sustaining treatment is grounded in the 1914 Supreme Court Ruling credited to Justice Benjamin Cardoza that "every human being of adult years of sound mind has the right to determine what shall be done with his own body." This ruling is blurred by the modern semantic issue of "allowing a patient to die" versus "euthanasia" versus "suicide." This excerpt from the PBS program "The Kevorkian Verdict" summarizes the current state of the law:
On July 26, 1997, the U.S. Supreme Court unanimously upheld decisions in New York and Washington State that criminalized assisted suicide. These decisions overturned rulings in the 2nd and 9th Circuit Courts of Appeal which struck down State statutes banning physician-assisted suicide. Those courts had found that the statutes, which prohibited doctors from prescribing lethal medication to competent, terminally ill adults, violated the 14th Amendment. In striking the appellate decisions, the U.S. Supreme Court found that there was no constitutional "right to die," but left it to individual states to enact legislation permitting or prohibiting physician-assisted suicide.
As of April 1999, physician-assisted suicide is illegal in all but a handful of states. Over thirty states have enacted statutes prohibiting assisted suicide, and of those that do not have statutes, a number of them arguably prohibit it through common law. In Michigan, Jack Kevorkian was initially charged with violating the state statute, in addition to first-degree murder and delivering a controlled substance without a license. The assisted suicide charge was dropped, however, and he was eventually convicted of second degree murder and delivering a controlled substance without a license.
Only one state, Oregon, has legalized assisted suicide. The Oregon statute, which went into effect in October 1997, provides that a doctor may prescribe, but not administer, a lethal dose of medication to a patient who has less than six months to live. Two doctors must agree that the patient is mentally competent and that the decision was voluntary. As of April 1999, 23 patients were given drugs under the statute, and 15 of them used the drugs to commit suicide. A report released by the Oregon State Health Division reviewing the first year of the law's implementation found that the law was working well and had not been subject to abuse.
At the federal level, the only legislation addressing this issue (as of April 1999), is the Assisted Suicide Funding Restriction Act. This law prohibits federal money from being used in support of physician assisted suicide. However, in 1998, House Judiciary Chairman Henry Hyde and Senator Don Nickles introduced bills in the House and Senate which would revoke the license to prescribe federally controlled drugs from any doctor who participated in an assisted suicide. If such legislation passed, doctors in Oregon, or any other state that legalized assisted suicide, would be subject to the federal sanction even though their actions were permitted under state law. The bills were not enacted into law before the end of the congressional session, but may be revived in 1999.
Although public opinion is in favor of the idea of "Death with Dignity," Kevorkian's approach is not favored. After the airing of the "60 Minutes" episode, which showed Kevorkian administering a lethal injection to 52 year old Thomas Youk, the Detroit Free Press polled viewers in Michigan and found that a majority, 45%, felt that Kevorkian should be convicted of a serious crime such as murder. Thirty percent of those polled felt he should be convicted of violating the ban on assisted suicide. In addition, when viewers were polled on the question of whether or not Kevorkian had gone too far by "trying to force the issue of assisted suicide and euthanasia by his actions, and, if necessary
starve himself in prison to become a martyr for his beliefs", 55% responded affirmatively.
Arthur Caplan, Director for the Center of Bioethics in Philadelphia, was interviewed by PBS on the issue of physician assisted suicide, and he stated that the duty of medicine is to try to talk people out of suicide, not promote it. He also commented that he worries that physician assisted suicide will become the attractive solution of first resort rather than the option of last resort. According to Caplan, "I think Dr. Kevorkian believes that the line medicine should draw around assisted suicide is neither around pain, nor around terminal illness
it must go further and that's where I expect him to be going. I expect him to be leading the charge to expand the right to die to those who say by their own free will or their own choice, "that's it for me." In psychiatry, this is called suicidal ideation and is a sign of depression, an illness that can be effectively treated in 65-85% of cases. To have thoughts of not wanting life to go on when someone is suffering may be normal, but to have the intent to take one's life through suicide definitely is not. I agree with Dr. Caplan's characterization of Kevorkian as a person who is obsessed with death, who can't accept it and who is trying to gain personal control and victory over it by saying, "I'll control the timing of it." In my opinion, suffering is the enemy in medicine, not death. Better palliative care should be the focus.
So what does this say about the state of end of life issues concerning mental health professionals? Kevorkian is not the only practitioner of physician assisted suicide, just the most widely known. There were shocking findings from a recent study out of Washington State that surveyed a large number of physicians. The results found that 16% of doctors surveyed had a genuine request from at least one patient in the prior year for an assisted death and one quarter of the doctors provided a lethal prescription. Of course, in cases like these, there is no consultation requested or provided. This issue has been around pre-Kevorkian, and it is here to stay. However, mental health professionals should be an integral part of policy development concerning end of life issues, as well as on the health care team. We are the ones to ensure depressed patients are not assisted in fulfilling their pathological intent for suicide. The medical profession has a long way to go to sort out this complex issue, and Dr. Kevorkian has helped heighten its emergency status.
As mental health professionals, we must take a leading role. Emergency situations are universal. It makes no difference whether a physician, a psychologist or a social worker is faced with an acutely suicidal or violent patient. The reality, as I alluded to above, is that mental health care needs to be a team approach, and each member can be faced with the same patient, the same emergency. How does the care team help the patient best? Each member being adequately prepared is a good place to start.
Roth, L., Meisel, A., & Lidz, C. (1977). Tests of competency to consent to treatment. American Journal of Psychiatry, 134, 279-284.
Thomas Cobb, M.D. is currently a psychiatry resident at the University of Michigan. His interests include psychiatric resident education, neuropsychiatry, theology and religious history. He has reviewed psychiatric texts for other publishers and hopes to publish in the field soon. Future plans are in academic psychiatry with a focus on integrative approaches to the patient, from neurons to philosophy.