Policies and Ethics in Healthcare
The Case of the Depressed Patient
The situation where patient R.L. is suffering from depression have rendered more complications to his overall health. But before persuading R.L. to agree to the medical procedures that he has to undergo, it is detrimental that his depression must be addressed first, otherwise, any persuasive efforts would render ineffective because of his depress condition. First thing first, is to analyze the causes of his depression and eradiate them one by one. The fact that his wife recently passed away, R.L. would have felt alone considering that his social behavior is weak and his only son is away from him. These factors elevated his belief that there is none left for him and that thought contributed to his depressed condition. Being depressed means not being able to think clearly or lacks the positive attitude and at his age he might be thinking that his life is not worth saving anymore. The very nature of men defined by masculinity often brings the notion of being strong at all times and that kind of thinking is prevalent in most men. When time comes that men’s emotional state is being challenged, it is difficult for them to express it for it will question their masculinity. The feeling of despair, hopelessness and loneliness are the things that difficult to express by men so the tendency is for them to deny it or cover it up. But as time goes by the accumulated mix of emotions would eventually burst out or put a toll on their health.
The truth about depression in men is that it can interfere with their personal and professional life including their ability to enjoy life. Men that suffer depression are said to be four times likely to commit suicide than women (Helpguide.org N.D.) and that explains the reason why R.L. is displaying disagreements to be treated because he cannot make a clear decision out of it. Depression is also the reason why his heart condition is failing leading to a chain of health problems. Providing informed consent maybe a good option because it is a legal procedure in which the patient will be informed of the risks and the cost involve of the treatment, its nature, alternatives and all the potential benefits and risk of the treatment (Thefreedictionary.com N.D.). In the normal process the patient or the responsible party would have to sign a document that will prove their understanding to the explained medical procedure. What needs to be ensured is the patient and the responsible party understands of the risk and benefits and everything has to be stipulated in the consent statement (Medterms.com N.D.). The problem here is that informed consent has to be voluntarily given and to be forced to the patient and with R.L.’s case he already showed refusal of the treatment even after he was given mood medication. Therefore, it is likely that R.L. would never sign the consent including his son and other options must be explored in order to save R.L.’s life.
In this situation, R.L.’s competence therefore has to be determined given that his decision making is suspected to be impaired by depression. A strike of balance has to be has to be considered aligned to the court’s perspectives. If there is a suspecting complexity in the patient’s decision capability, calling for a psychiatric assistance is necessary. The family members would not be allowed to intervene in the decision making process unless the psychologist have identified mental incapacity in the patient. However, normal cases would only call for a simple instrument to screen the patient, but up to now the neuropsychological test still have not provided concise and accurate assessments. The other option for testing is called the Mini Mental State Examination or (MMSE); this kind of test can correlate clinical judgments of incapacity. MMSE would be helpful in producing consistent findings especially for patients like R.L. who is an elderly and most of the elderly people already have decreased cognitive function. The MMSE test will determine cognitive capacity using score range from 0 to 30. Any patient tested with a score lower than 16 are potentially incompetent and those scoring between 23 and 26 are evidently competent. Currently, there are no formal guidelines for health professionals in terms of competence assessment in relation to providing informed consent for treatment (Appelbaum, Paul S. M.D. November 1, 2007).
For elderly patients the suicidal tendencies are high, even though the elderly population only makes up 10% of the total population they still account to 25% of suicide incidents caused by alcoholism and depression. Those are the two psychiatric conditions that are being associated with suicide incidents in the geriatric population (Nicholas, Linda M. M.D, MS. 2001). R.L.’s physician should have addressed the depression problem immediately. The doctor has the responsibility to look into R.L’s suicidal tendencies and handled it differently given the history of the patient’s cause of depression. The fact that R.L.’s wife passed away his tendencies would be higher as the figures show that widowed, separated and divorced men are four to five times likely to commit suicide (Nicholas, Linda M. M.D, MS. 2001), therefore clinical assessments should have been initiated right away.
Right at the onset of depression development in the patient, he should have been immediately given psychological briefing. Since R.L. is an elderly and that assumes the fact that he is no longer employed, it also shifts his perception of usefulness and self worth, thus contributes to depression. The doctor could have employed a mental status examination and it has to be done regularly. Preventive measure is necessary in determining the best practices to perform to prevent the patient from further sinking in depression. Determining individual risk factors are also important. The degree of hopelessness and sadness should have been assessed because hopelessness is a symptom associated to risk of developing suicide tendencies. If suicidal thoughts are present the moods are also affected, thus monitoring how the mood swings is also detrimental in initiating preventive actions. In most cases psychosocial and psychological intervention would be helpful such as behavioral and cognitive psychotherapy.
With the situation that the patient (R.L.) is facing, his decision whether to continue with dialysis has to be respected for autonomy reasons. There are several cases in the past that the health professional didn’t get the credits or a gesture of thanks but instead received a court subpoena for saving the life of a patient that doesn’t want to be saved. There was this movie entitled “The Incredibles”, an animated movie about a family of super heroes; the dad (Mr. Incredible) was a dedicated superhero back in his days until he was sued by one of the people he saved who didn’t want to be saved at all. The metaphor in which this movie although entirely not related to medical practices showed how people are unique in their choices of how they want to end their own life and to be interfered without their permission even for a favorable advantage is a big mistake. No matter how noble the physician’s intent to prolong the life of his patients, it is still the patients best interest that should prevail. The consent to be treated or not is with the discretion of the patient himself, even if he is not in the right state of mind to decide for the matter because of depression, the law favors his autonomy.
It is clear that R.L. is not insane enough yet to deny his autonomy for consent, however considering his condition, additional help is needed to determine the extent of the patient’s right to be treated versus the physician’s position as the life preserver. If the patient is refusing to be treated informed consent is the best option to explain the situation to the patient and the family member for them to understand the risks involve and the benefits of undergoing the treatment process. If the patient and the family members still refused, it is no longer the doctor’s responsibility whatever the outcome of the decision is. Besides being overly persuasive on the part of the doctor would only cause trouble for him since the court jurisdiction in the matter is that the patient has the absolute right to refuse or accept treatment.
Helpguide.org. (N.D.) Depression in Men: UNDERSTANDING AND DEALING WITH MALE DEPRESSION Web Retrieved April 1, 20012 from http://www.helpguide.org/mental/depression_men_male.htm
Thefreedictionary.com. (N.D.) informed consent Web Retrieved April 1, 20012 from http://www.thefreedictionary.com/informed+consent
Medterms.com. (N.D.) Definition of Informed consent Web Retrieved April 1, 20012 from http://www.medterms.com/script/main/art.asp?articlekey=22414
Kleinman, Erwin M.D (1991) the right to refuse treatment: ethical considerations for the competent patient Web Retrieved April 1, 2012 from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1335174/pdf/cmaj00239-0029.pdf
Appelbaum, Paul S. M.D (November 1, 2007) Assessment of Patients' Competence to Consent to Treatment Web Retrieved April 1, 2012 from http://www.nejm.org/doi/full/10.1056/NEJMcp074045
Nicholas, Linda M. M.D, MS. (2001) Managing the Suicidal Patient Web Retrieved April 1, 2012 from http://www.dangerousbehaviour.com/Disturbing_News/Managing%20the%20Suicidal%20Patient.htm