Psychiatry - October 2008 - (Page 45)

ete cs i r ase] [ t h h i i n t en f p c y c h i a t r y ] recommend that care providers suggest to these patients that they hope for the best while still anticipating the possibility of the worst. The authors suggest this may enable patients to better accept their worst-case scenario, while at the same time leaving them hope.17 This same kind of approach may be optimal also for families of patients in denial, again, before the patient’s prognosis is known. Psychiatrists can ask families, “Are there things you would want to say…just in case?” A mental health worker who asks families this question reports that after patients die, the families are grateful because they make “allowance in their calculations for their loved one’s demise….”18 Patients may in some cultures wish to defer this information to their families.19 In most other contexts, however, patients and their families may benefit optimally by being able to share with each other what they have meant to each other at the patient’s end of life. Here, again, as with genetic screening, psychiatrists may be able to respond most effectively to patients’ and their families’ needs only if they can anticipate these needs before the patient’s prognosis is established. Before this occurs, psychiatrists can ask patients and families what they would want if the patient’s illness is fatal. If the psychiatrist already knows that the prognosis is fatal, however, he or she may then have to implicitly lie. The psychiatrist also may harm the patient by “letting the cat [that the patient has a fatal illness] out of the bag.” A final example involves e-mails. It may be helpful for psychiatrists to communicate with their patients by e-mails. E-mail communication may, for example, be very convenient for patients when they need to refill prescriptions. There are, however, several risks to communicating with patients via email.20–22 One risk is that patients may send messages to their psychiatrists saying they feel suicidal. They may unconsciously hope that their psychiatrists will read and respond before they decide to end their lives. Psychiatrists may be able to reduce this risk by simply anticipating it. Whenever any patient asks to e-mail the psychiatrist, the psychiatrist should be very specific on what types of e-mails are acceptable and why. The psychiatrist may anticipate, however, that a particular patient might e-mail him those they evaluate that they are not primarily serving their interests.23 Forensic psychiatrists must be particularly careful in this regard not to use their psychiatric skills of enhancing patients’ bonding by showing too much empathy.24 If they do, this could exploit the patients’ emotional vulnerability to serve others’ interests. As experts in this field say, “… even the legitimate use of empathy can lead to a quasitherapeutic interaction that ultimately leaves the evaluatee feeling betrayed by the evaluator’s report.”25 This consideration may apply whenever a psychiatrist may serve Forensic psychiatrists must be particularly careful not to use their psychiatric skills of enhancing patients’ bonding by showing too much empathy.24 If they do, this could exploit the patients’ emotional vulnerability to serve others’ interests. or her messages that express suicidal thoughts, and unless the psychiatrist is checking his or her email every moment of every day, the e-mail option for this particular patient is probably not appropriate. The real “why,” which is explained to the patient, would include the psychiatrist’s own feelings. In this case, the psychiatrist would explain to the patient his or her own fear of not getting a suicidal message in time to help the patient. others’ interests. It is morally obligatory, then, for psychiatrists to try to discern for themselves whenever this may be the case. I recall being asked to consult for primarily clinical and teaching purposes in a case with a patient who was giving her young daughter many herbs. The psychiatrists who consulted with me wanted me to help them determine both how to help this mother maximally and whether or not she posed a danger to her child. I could and should have warned this patient of my second, quasiforensic purpose here, but I did not. I did not warn her, perhaps, because I feared that I would be letting the other psychiatrists down. If I warned her, she might have chosen not to say anything, which may have been a reasonable response on her part, as [OCTOBER] WARNING PATIENTS In some situations, psychiatrists may respect patients optimally by warning them (in advance) that they (the psychiatrists) may later act against patient interests. This ethical duty is exemplified best, perhaps, in forensic evaluations. Here, psychiatrists routinely inform Psychiatry 2008 45

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Psychiatry - October 2008 Editor’s Message Editorial Advisory Board Contents Psych Rx Treatment of Migraine and the Role of Psychiatric Medications Play Therapy: A Case-based Example of a Nondirective Approach Delirium and Antipsychotics: A Systematic Review of Epidemiologyand Somatic Treatment Options Severely Mood-disordered Youth Respond Less Well to Treatment in a Community Clinic than Youth with Bipolar Disorder Beyond Informed Consent: The Ethics of Informing, Anticipating, and Warning Asthma: Wheezing, Woes, and Worries Classified Advertising Journal Watch Information for Authors

Psychiatry - October 2008

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