Ethics case quiz | Food for Thought

Case summary

Mr. B is an 85-year-old widower and retired carpenter. He is admitted to a psychiatric ward from the dementia care facility where he resides after becoming agitated and striking a caregiver who was trying to bathe him. He has also become increasingly aggressive during any group activities, sometimes pushing other residents.

Mr. B had a small stroke 5 years earlier. Although he was left without any major physical sequelae, he received a diagnosis of vascular dementia that year, and his neurologist prescribed 5 mg of donepezil. A year later he received a diagnosis of depression, and the psychiatrist began treatment with escitalopram at a dose of 10 mg. There was notable improvement with the antidepressant, and Mr. B became more sociable and interested in the various activities at his adult day care.

Six months ago, the dementia progressed and he began to wander. His daughter, who had become his primary caregiver when his wife died 2 years earlier, could no longer safely care for him in her home. A neuropsychologist at the university evaluated the patient and found him to lack capacity for medical, financial, and disposition decisions. Before losing capacity, he had appointed his daughter as his medical power of attorney and his son as his financial power of attorney.

While Mr. B is on the psychiatric ward, escitalopram and donepezil are continued. Medical records from the dementia care facility indicate that several atypical antipsychotics were tried but had little effect on the behavioral disturbances of dementia. They were discontinued after the patient’s daughter raised concern about the black box warning of this class of drugs when used in patients with dementia. The attending psychiatrist prescribes immediate-release valproic acid at 250 mg every 8 hours. Within a few days, Mr. B is calmer and seems less irritable. By the end of the week, Mr. B’s mood and behavior are so much better that at rounds the plan is made to discharge the patient back to his care facility on Monday.

Over the weekend, Mr. B begins to refuse the valproic acid. He tells the staff that “it tastes bad” and then at other times, “You are trying to control me with it.” He is erratic in taking his other medications but closes his mouth and crosses his arms when the nurses try to give him the mood stabilizer. By Sunday night, Mr. B is so aggressive and angry that he requires a crisis team to administer 2.5 mg of olanzapine intramuscularly to keep him from harming himself and the staff. The incident is distressing for Mr. B, for the other patients, and for the staff.

The unit psychologist and occupational therapist try different behavioral techniques and environmental adjustments to form an alliance with Mr. B, but they are unable to persuade him to take the valproic acid willingly. Mr. B’s behavior steadily deteriorates and requires several more episodes of forced medication. The attending geriatric psychiatrist calls the staff together for a case conference with a psychiatric pharmacy consultant to discuss the situation. The pharmacist suggests a trial of divalproex sprinkles that could be put in applesauce or ice cream.

The treatment team is sharply divided over whether it is ethical to administer a medication to a patient -even an incapacitated patient -without his knowledge. The psychologist especially feels that this would be tantamount to deceiving the patient and that it is categorically always wrong to lie to patients. Some of the nursing staff believe that putting the medication in Mr. B’s food is far kinder than the repeated takedowns. The team cannot reach agreement except on the need to request an ethics consultation.

PLEASE VOTE FOR YOUR CHOICES -and post your comments. I’ll offer a discussion of your comments and commentary about the ethical concerns and questions this case raises in a coming issue of Psychiatric Times.

The ethics consultation questions

You are the leader of the 3-person team assigned to perform the ethics consultation. The medical director of the geriatric psychiatry unit has prepared the case summary for you to review before you meet with the team. After you review it, you sketch the following questions as food for thought.

1 When you review the case summary, the opinion of the psychologist is clearly most consistent with which major ethical theory or model?

A. Consequentialist theory that the end justifies the means and if deception will prevent harm to patient and staff in this case, it is ethical.

B. Deontological theory that there are certain near absolutes, one of which is that lying for any reason violates the respect all human beings deserve.

C. Virtue theory that a good clinician puts the patient first and remains faithful to the patient’s well-being.

D. Principlist theory that beneficence may outweigh autonomy when all circumstances are specified and analyzed.

2 Glaringly absent from the summary is any discussion with the daughter, the son, or any other family member. Which of the following is the most accurate statement about the daughter’s ability to consent to concealed medication?

A. As the health care agent, the daughter can legally and ethically provide informed consent for the surreptitious use of the medication.

B. Even as the health care agent, the daughter cannot provide consent for another human being to be deceived with concealed medication.

C. The daughter cannot provide consent for the surreptitious use of the medication because the patient is in a psychiatric hospital; only a court can order it.

D. The daughter would need to be the patient’s guardian to provide consent for a concealed medication.

3 An essential aspect of an ethics consultant’s job is to help the group formulate all of the ethically justifiable conditions under which a particular decision may be made. Assume the daughter consents to the covert administration of medication because she wants the patient to be able to return to his dementia care home. Which of the following conditions would you NOT recommend be included in the treatment plan to enhance the ethical quality of the surreptitious use of medication?

A. The covert administration of the medication should be time-limited and monitored to assess its efficacy and any adverse effects.

B. The treatment plan should not be formally written out but verbally agreed to by all staff.

C. The staff should no longer attempt to persuade the patient to take the medication voluntarily because it endangers the staff and other patients.

D. Staff who object to the use of concealed medication should not be permitted to request recusal from the care of the patient because this places an unfair burden on the rest of the team.

4 One of the primary tasks of the ethics consultant is to help the daughter and treatment team to identify the values conflicts involved in the decision. Which of the following values most strongly argues against the use of covert medication for Mr. B?

A. It is more ethical to use prn medications when all other nonpharmacological means fail to control behavior that can endanger the patient and the staff than to schedule concealed medications.

B. The daughter seems to be consenting only because she wants the patient to go back to his nursing home and so does not appear to be acting in the patient’s best interests.

C. So long as the patient is combative and agitated he cannot be discharged back to his assisted care facility, where he would likely have a better quality of life.

D. Deceiving the patient risks having him discover the covert medication, lose trust in the team, and become even more paranoid and challenging to manage.

MORE ABOUT Cynthia Geppert, MD, MA, MSBE, DPS

I come from a family of musicians and physicians. My father was an Army doctor during WWII and was one of the founders of military pediatrics. My brother is the award-winning artist Christopher Cross. I spent my youth as a rock and roll drummer and always thought I would end up being a teacher or writer but never a doctor because I was a failure as a student. My teachers thought I had learning disabilities, and I dropped out of high school when I turned 16. Somehow, I managed to graduate from college and spent most of my early career studying and teaching religion and working in various aspects of ministry.

While visiting a sick parishioner, I had a spiritual experience that I needed to try to do more to relieve not just the spiritual but also the physical and mental suffering of human beings. So, in my thirties I decided to go to medical school despite having a third-grade math level and never having taken a chemistry course. It was a very long and difficult journey.

In medical school, I finally found a way to integrate the humanities and medicine in the field of bioethics. I never intended to do a residency, but my philosophy professor in graduate school told me that to be relevant as an ethicist you must take care of patients, and he was right. I was drawn to internal medicine but had some serious health problems that made that impossible and ended up where I should have been all along -in consultation psychiatry.

As an intern, I sent an essay to Psychiatric Times that was accepted and am grateful to be involved with the publication ever since. Ron Pies, MD, has been my mentor on this path and though I will never equal his brilliance, my aspiration is to be the same breed of renaissance thinker.

Caring for patients, teaching, and writing are such a privilege and pleasure for me that I cannot really call them work. I guess if I had to name a hobby, it would probably be collecting board certifications and advanced degrees because I love learning. But I also enjoy riding trikes with my wife and hiking with my beloved dogs in the beautiful New Mexico mountains where we live.