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FOCUS, VOL. 1, No. 4

CLINICAL SYNTHESIS | October 01, 2003

Quick Reference for Forensic and Ethical Issues in Psychiatry

FOCUS 2003;1:345-348.

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The tables in this section are from Simon RI: Concise Guide to Psychiatry and Law for Clinicians, 3rd ed. Washington, DC, American Psychiatric Publishing, 2001. Copyright 2001 American Psychiatric Publishing, Inc.

Table 1. The Four Ds of a Malpractice Claim

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A doctor-patient relationship must be present, creating the following:

DUTY of care.

DEVIATION from the standard of care must have occurred.

DAMAGE to the patient must have occurred.

The damage must have occurred DIRECTLY as a result of the deviation from the standard of care.

Table 2. Actions by Therapists That May Create a Doctor-Patient Relationship

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Giving advice to prospective patients, friends, and neighbors

Making psychological interpretations during an independent evaluation

Writing a prescription or providing sample medications

Supervising treatment by a nonmedical therapist

Having a lengthy phone conversation with a prospective patient

Treating an unseen person by mail

Giving a prospective patient an appointment

Telling walk-in prospective patients that they will be seen

Acting as a substitute therapist

Providing treatment during an evaluation

Table 3. Suggested Guidelines for Termination of Patient Treatment

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Thoroughly discuss treatment termination with patient.
Indicate the following in a letter of termination:
- Fact of discussion of termination
- Reason for termination
- Termination date
- Availability for emergencies only until date of termination
- Willingness to provide names of other appropriate therapists
- Willingness to provide medical records to subsequent therapist
- A statement of the need for additional treatment, if appropriate
Allow the patient reasonable time to find another therapist (length of time depends on availability of other therapists).
Provide the patient’s records to the new therapist upon proper authorization by the patient.
If the patient requires further treatment, provide the names of other psychiatrists or refer the patient to a local or state psychiatric society for further assistance.
If the need for further treatment is recommended, a statement about the potential consequences of not obtaining further treatment should be provided.
Send the termination letter certified or restricted registered mail, return receipt requested.

Table 4. Examples of Statutory Disclosure Requirements

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Evidence of child abuse

Initiation of involuntary hospitalization

"Duty to warn" endangered third parties or law enforcement agencies

Commission of a past treasonous act

Intention to commit a future crime

Human immunodeficiency virus (HIV) infection^a

a Some states require that the patient’s name be reported.

Table 5. Informed Consent: Reasonable Information to Be Disclosed

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Although there exists no consistently accepted set of information to be disclosed for any given medical or psychiatric situation, as a rule of thumb, five areas of information are generally provided:

Diagnosis: description of the condition or problem
Treatment: nature and purpose of proposed treatment
Consequences: risks and benefits of the proposed treatment
Alternatives: viable alternatives to the proposed treatment, including risks and benefits
Prognosis: projected outcome with and without treatment

Table 6. Indications for Seclusion and Restraint

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To prevent clear, imminent harm to the patient or others

To prevent significant disruption to treatment program or physical surroundings

To assist in treatment as part of ongoing behavior therapy

To decrease sensory overstimulation^a

To comply with patient's voluntary reasonable request^b

a Seclusion only

b First seclusion; then, if necessary, restraints

Table 7. Contraindications to Seclusion and Restraint

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For extremely unstable medical and psychiatric conditions^a

For patients with delirium or dementia who are unable to tolerate decreased stimulation^a

For overtly suicidal patients^a

For patients with severe drug reactions, those with overdoses, or those requiring close monitoring of drug dosages^a

For punishment of the patient or convenience of staff

a Unless close supervision and direct observation are provided.

Table 8. Demonstration of a Rapid, Competent Suicide Risk Assessment

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Risk Factor	Facilitating Suicide	Inhibiting
Anxiety	M
Loss of pleasure and interest in child	H
Depressive turmoil	M
Diminished concentration	L
Therapeutic alliance		H
Family relations		M
Hopelessness	L
Psychiatric diagnosis	M
Prior attempts	O	O
Current attempt (lethality)	H
Specific plan	O	O
Living situation		H
Employment		L
Availability of gun	M
Suicidal ideation/intent	L (passive)
Family history	H
Impulsivity	M—H
Drug/alcohol	O
Depression/postpartum	M
Religion		L—M
Insomnia	L
Other children		H
Physical condition		M
Cognition/competence		M—H
Marital relationship		M—H
Overall Risk Rating: moderate—high (at discharge) L = low; M = moderate; H = high; 0 = nonfactor

Table 9. Clinical Risk Factors Associated With Violence

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The stated desire to hurt or kill another

History of violence

Alcohol and substance abuse

Inability to control anger

Impulsivity (e.g., previous violence toward others or self, reckless driving, unrestrained spending, sexual promiscuity)

Paranoid ideation, thought insertion or control, fear of harm

Command hallucinations

Psychosis

Personality disorders: antisocial, borderline, and organic personality disorder (explosive type)

"Soft" neurological signs

Substance abuse

Low intelligence

Table 10. Demonstration of a Rapid, Competent Violence Risk Assessment

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Risk Factor	Facilitating Violence	Inhibiting Violence
Specific person threatened	O (in hospital)	O
Past violence	H (stabbed cousin)
Accessible victim	H (mother)
Therapeutic alliance		L—M (with staff)
Psychiatric diagnosis	H
Command hallucinations	O (in hospital)	O
Employment		L
Specific plan	O	O
Treatment response		H
Medication compliance		H (in hospital)
Structured environment		H
Alcohol dependence	H
Substance abuse	O	O
History of impulsivity	H
Guns		L (none at home)
Compliance with aftercare	H
Relationships	M—H (loner)
Overall Risk Rating: low (at discharge) L = low; M = moderate; H = high; 0 = nonfactor

Table 1. The Four Ds of a Malpractice Claim

View Large | Add to My POL

A doctor-patient relationship must be present, creating the following:

DUTY of care.

DEVIATION from the standard of care must have occurred.

DAMAGE to the patient must have occurred.

The damage must have occurred DIRECTLY as a result of the deviation from the standard of care.

Table 2. Actions by Therapists That May Create a Doctor-Patient Relationship

View Large | Add to My POL

Giving advice to prospective patients, friends, and neighbors

Making psychological interpretations during an independent evaluation

Writing a prescription or providing sample medications

Supervising treatment by a nonmedical therapist

Having a lengthy phone conversation with a prospective patient

Treating an unseen person by mail

Giving a prospective patient an appointment

Telling walk-in prospective patients that they will be seen

Acting as a substitute therapist

Providing treatment during an evaluation

Table 3. Suggested Guidelines for Termination of Patient Treatment

View Large | Add to My POL

Thoroughly discuss treatment termination with patient.
Indicate the following in a letter of termination:
- Fact of discussion of termination
- Reason for termination
- Termination date
- Availability for emergencies only until date of termination
- Willingness to provide names of other appropriate therapists
- Willingness to provide medical records to subsequent therapist
- A statement of the need for additional treatment, if appropriate
Allow the patient reasonable time to find another therapist (length of time depends on availability of other therapists).
Provide the patient’s records to the new therapist upon proper authorization by the patient.
If the patient requires further treatment, provide the names of other psychiatrists or refer the patient to a local or state psychiatric society for further assistance.
If the need for further treatment is recommended, a statement about the potential consequences of not obtaining further treatment should be provided.
Send the termination letter certified or restricted registered mail, return receipt requested.

Table 4. Examples of Statutory Disclosure Requirements

View Large | Add to My POL

Evidence of child abuse

Initiation of involuntary hospitalization

"Duty to warn" endangered third parties or law enforcement agencies

Commission of a past treasonous act

Intention to commit a future crime

Human immunodeficiency virus (HIV) infection^a

a Some states require that the patient’s name be reported.

Table 5. Informed Consent: Reasonable Information to Be Disclosed

View Large | Add to My POL

Although there exists no consistently accepted set of information to be disclosed for any given medical or psychiatric situation, as a rule of thumb, five areas of information are generally provided:

Diagnosis: description of the condition or problem
Treatment: nature and purpose of proposed treatment
Consequences: risks and benefits of the proposed treatment
Alternatives: viable alternatives to the proposed treatment, including risks and benefits
Prognosis: projected outcome with and without treatment

Table 6. Indications for Seclusion and Restraint

View Large | Add to My POL

To prevent clear, imminent harm to the patient or others

To prevent significant disruption to treatment program or physical surroundings

To assist in treatment as part of ongoing behavior therapy

To decrease sensory overstimulation^a

To comply with patient's voluntary reasonable request^b

a Seclusion only

b First seclusion; then, if necessary, restraints

Table 7. Contraindications to Seclusion and Restraint

View Large | Add to My POL

For extremely unstable medical and psychiatric conditions^a

For patients with delirium or dementia who are unable to tolerate decreased stimulation^a

For overtly suicidal patients^a

For patients with severe drug reactions, those with overdoses, or those requiring close monitoring of drug dosages^a

For punishment of the patient or convenience of staff

a Unless close supervision and direct observation are provided.

Table 8. Demonstration of a Rapid, Competent Suicide Risk Assessment

View Large | Add to My POL

Risk Factor	Facilitating Suicide	Inhibiting
Anxiety	M
Loss of pleasure and interest in child	H
Depressive turmoil	M
Diminished concentration	L
Therapeutic alliance		H
Family relations		M
Hopelessness	L
Psychiatric diagnosis	M
Prior attempts	O	O
Current attempt (lethality)	H
Specific plan	O	O
Living situation		H
Employment		L
Availability of gun	M
Suicidal ideation/intent	L (passive)
Family history	H
Impulsivity	M—H
Drug/alcohol	O
Depression/postpartum	M
Religion		L—M
Insomnia	L
Other children		H
Physical condition		M
Cognition/competence		M—H
Marital relationship		M—H
Overall Risk Rating: moderate—high (at discharge) L = low; M = moderate; H = high; 0 = nonfactor

Table 9. Clinical Risk Factors Associated With Violence

View Large | Add to My POL

The stated desire to hurt or kill another

History of violence

Alcohol and substance abuse

Inability to control anger

Impulsivity (e.g., previous violence toward others or self, reckless driving, unrestrained spending, sexual promiscuity)

Paranoid ideation, thought insertion or control, fear of harm

Command hallucinations

Psychosis

Personality disorders: antisocial, borderline, and organic personality disorder (explosive type)

"Soft" neurological signs

Substance abuse

Low intelligence

Table 10. Demonstration of a Rapid, Competent Violence Risk Assessment

View Large | Add to My POL

Risk Factor	Facilitating Violence	Inhibiting Violence
Specific person threatened	O (in hospital)	O
Past violence	H (stabbed cousin)
Accessible victim	H (mother)
Therapeutic alliance		L—M (with staff)
Psychiatric diagnosis	H
Command hallucinations	O (in hospital)	O
Employment		L
Specific plan	O	O
Treatment response		H
Medication compliance		H (in hospital)
Structured environment		H
Alcohol dependence	H
Substance abuse	O	O
History of impulsivity	H
Guns		L (none at home)
Compliance with aftercare	H
Relationships	M—H (loner)
Overall Risk Rating: low (at discharge) L = low; M = moderate; H = high; 0 = nonfactor

References

CME Activity

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Sample questions:

The bioethical principle of fidelity refers to the physician’s obligation to:

The most basic ethical skill of the physician is:

The ethically problematic situation that arises when a psychiatrist is the therapist for both an individual and members of his family is called:

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Quick Reference for Forensic and Ethical Issues in Psychiatry. FOCUS: The Journal of Lifelong Learning in Psychiatry. 2003 Oct;1(4):345-348.

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