Should Patients Be Allowed to Die From Anorexia? Is a 'Palliative' Approach to Mental Illness Ethical?

Katie Engelhart

New York Times Magazine

Originally posted 3 Jan 24

Here is an excerpt:

He came to think that he had been impelled by a kind of professional hubris — a hubris particular to psychiatrists, who never seemed to acknowledge that some patients just could not get better. That psychiatry had actual therapeutic limits. Yager wanted to find a different path. In academic journals, he came across a small body of literature, mostly theoretical, on the idea of palliative psychiatry. The approach offered a way for him to be with patients without trying to make them better: to not abandon the people who couldn’t seem to be fixed. “I developed this phrase of ‘compassionate witnessing,’” he told me. “That’s what priests did. That’s what physicians did 150 years ago when they didn’t have any tools. They would just sit at the bedside and be with somebody.”

Yager believed that a certain kind of patient — maybe 1 or 2 percent of them — would benefit from entirely letting go of standard recovery-oriented care. Yager would want to know that such a patient had insight into her condition and her options. He would want to know that she had been in treatment in the past, not just once but several times. Still, he would not require her to have tried anything and everything before he brought her into palliative care. Even a very mentally ill person, he thought, was allowed to have ideas about what she could and could not tolerate.

If the patient had a comorbidity, like depression, Yager would want to know that it was being treated. Maybe, for some patients, treating their depression would be enough to let them keep fighting. But he wouldn’t insist that a person be depression-free before she left standard treatment. Not all depression can be cured, and many people are depressed and make decisions for themselves every day. It would be Yager’s job to tease out whether what the patient said she wanted was what she authentically desired, or was instead an expression of pathological despair. Or more: a suicidal yearning. Or something different: a cry for help. That was always part of the job: to root around for authenticity in the morass of a disease.

The info is here.

Some thoughts:

The question of whether patients with anorexia nervosa should be allowed to die from their illness or receive palliative care is a complex and emotionally charged one, lacking easy answers. It delves into the profound depths of autonomy, mental health, and the very meaning of life itself.

The Anorexic's Dilemma:

Anorexia nervosa is a severe eating disorder characterized by a relentless pursuit of thinness and an intense fear of weight gain. It often manifests in severe food restriction, excessive exercise, and distorted body image. This relentless control, however, comes at a devastating cost. Organ failure, malnutrition, and even death can be the tragic consequences of the disease's progression.

Palliative Care: Comfort Not Cure:

Palliative care focuses on symptom management and improving quality of life for individuals with life-threatening illnesses. In the context of anorexia, it would involve addressing physical discomfort, emotional distress, and spiritual concerns, but without actively aiming for weight gain or cure. This raises numerous ethical and practical questions:

• Respecting Autonomy: Does respecting a patient's autonomy mean allowing them to choose a path that may lead to death, even if their decision is influenced by a mental illness?
• The Line Between Choice and Coercion: How do we differentiate between a genuine desire for death and succumbing to the distorted thinking patterns of anorexia?
• Futility vs. Hope: When is treatment considered futile, and when should hope for recovery, however slim, be prioritized?

Finding the Middle Ground:

There's no one-size-fits-all answer to this intricate dilemma. Each case demands individual consideration, taking into account the patient's mental capacity, level of understanding, and potential for recovery. Open communication, involving the patient, their family, and a multidisciplinary team of healthcare professionals, is crucial in navigating this sensitive terrain.

Potential Approaches:

• Enhanced Supportive Care: Focusing on improving the patient's quality of life through pain management, emotional support, and addressing underlying psychological issues.
• Conditional Palliative Care: Providing palliative care while continuing to offer and encourage life-sustaining treatment, with the possibility of transitioning back to active recovery if the patient shows signs of willingness.
• Advance Directives: Encouraging patients to discuss their wishes and preferences beforehand, allowing for informed decision-making when faced with difficult choices.

A fate worse than death

Cathy Rentzenbrink
Prospect Magazine
Originally posted March 18, 2018

Here is an excerpt:

We have lost our way with death. Improvements in medicine have led us to believe that a long and fulfilling life is our birthright. Death is no longer seen as the natural consequence of life but as an inconvenient and unjust betrayal. We are in an age of denial.

Why does this matter? Why not allow ourselves this pleasant and surely harmless delusion? It matters because we are in a peculiar and precise period of history where our technological advances enable us to keep people alive when we probably shouldn’t. Life or death is no longer a black and white situation. There are many and various shades of grey. We behave as though death is the worst outcome, but it isn’t.

Many years after the accident, when I wrote a book about it called The Last Act of Love, I catalogued what happened to me as I witnessed the destruction of my brother. I detailed the drinking and the depression. The hardest thing was tracking our journey from hope to despair. I still find it hard to be precise about exactly when and how I realised that Matty would be better off dead. I know I moved from being convinced that if I tried hard enough I could bring Matty back to life, to thinking I should learn to love him as he was. Eventually I asked myself the right question: would Matty himself want to be alive like this? Of course, the answer was no.

The info is here.

Alone Together: Who's Lonely and How Do We Measure It?

Tom Harrison
The RSA.org
Originally published January 18, 2018

Here is an excerpt:

What affect does loneliness have on our health?

Neuroscientist John Cacioppo’s seminal work published in ‘Loneliness: Human Nature and Need for Social Connection’ was one of the first to study the health impacts of loneliness. He found that lonely people have a 20 per cent higher premature mortality rate and called for a culture shift that would see loneliness as important a public health issue as obesity. The Campaign to End Loneliness acknowledges this; reporting that 3 out of 4 GPs say they see between 1 and 5 people a day who have come in mainly because they are lonely.

Indeed, research tells us that this phenomenon goes far beyond the familiar stereotype of an isolated grandmother. A recent British Red Cross report found that 32 per cent of those aged 16-24 reported that in the past 2 weeks they had often or always felt lonely. Are 1/3 of young people just snowflakes? It seems unlikely.

This has contributed to pressure for government to respond. But how do we measure the problem and what are responses required to tackle it?

The article is here.

Note to Reader: Psychotherapy can help with loneliness.

Moral distress in physicians and nurses: Impact on professional quality of life and turnover

Austin, Cindy L.; Saylor, Robert; Finley, Phillip J.
Psychological Trauma: Theory, Research, Practice, and Policy, Vol 9(4), Jul 2017, 399-406.

Abstract

Objective: The purpose of this study was to investigate moral distress (MD) and turnover intent as related to professional quality of life in physicians and nurses at a tertiary care hospital.

Method: Health care providers from a variety of hospital departments anonymously completed 2 validated questionnaires (Moral Distress Scale–Revised and Professional Quality of Life Scale). Compassion fatigue (as measured by secondary traumatic stress [STS] and burnout [BRN]) and compassion satisfaction are subscales which make up one’s professional quality of life. Relationships between these constructs and clinicians’ years in health care, critical care patient load, and professional discipline were explored.

Results: The findings (n = 329) demonstrated significant correlations between STS, BRN, and MD. Scores associated with intentions to leave or stay in a position were indicative of high verses low MD. We report highest scoring situations of MD as well as when physicians and nurses demonstrate to be most at risk for STS, BRN and MD. Both physicians and nurses identified the events contributing to the highest level of MD as being compelled to provide care that seems ineffective and working with a critical care patient load >50%.

Conclusion: The results from this study of physicians and nurses suggest that the presence of MD significantly impacts turnover intent and professional quality of life. Therefore implementation of emotional wellness activities (e.g., empowerment, opportunity for open dialog regarding ethical dilemmas, policy making involvement) coupled with ongoing monitoring and routine assessment of these maladaptive characteristics is warranted.

The article is here.

Living with the animals: animal or robotic companions for the elderly in smart homes?

Dirk Preuß and Friederike Legal
J Med Ethics doi:10.1136/medethics-2016-103603

Abstract

Although the use of pet robots in senior living facilities and day-care centres, particularly for individuals suffering from dementia, has been intensively researched, the question of introducing pet robots into domestic settings has been relatively neglected. Ambient assisted living (AAL) offers many interface opportunities for integrating motorised companions. There are diverse medical reasons, as well as arguments from animal ethics, that support the use of pet robots in contrast to living with live animals. However, as this paper makes clear, we should not lose sight of the option of living with animals at home for as long as possible and in conformity with the welfare of the animal assisted by AAL technology.

The article is here.

Moral Distress in Physicians and Nurses: Impact on Professional Quality of Life and Turnover.

C. L. Austin, R. Saylor, and P. J. Finley
Psychological Trauma: Theory, Research, Practice, and Policy, 2016

Abstract

Objective: The purpose of this study was to investigate moral distress (MD) and turnover intent as related to professional quality of life in physicians and nurses at a tertiary care hospital.

Method: Health care providers from a variety of hospital departments anonymously completed 2 validated questionnaires (Moral Distress Scale–Revised and Professional Quality of Life Scale). Compassion fatigue (as measured by secondary traumatic stress [STS] and burnout [BRN]) and compassion satisfaction are subscales which make up one’s professional quality of life. Relationships between these constructs and clinicians’ years in health care, critical care patient load, and professional discipline were explored.

Results: The findings (n = 329) demonstrated significant correlations between STS, BRN, and MD. Scores associated with intentions to leave or stay in a position were indicative of high verses low MD. We report highest scoring situations of MD as well as when physicians and nurses demonstrate to be most at risk for STS, BRN and MD. Both physicians and nurses identified the events contributing to the highest level of MD as being compelled to provide care that seems ineffective and working with a critical care patient load >50%.

Conclusion: The results from this study of physicians and nurses suggest that the presence of MD significantly impacts turnover intent and professional quality of life. Therefore implementation of emotional wellness activities (e.g., empowerment, opportunity for open dialog regarding ethical dilemmas, policy making involvement) coupled with ongoing monitoring and routine assessment of these maladaptive characteristics is warranted.

The article is here.

Dear Donald Trump: I treat combat veterans with PTSD, and they are not weak

Joan Cook
The Conversation
Originally published October 5, 2016

Here is an excerpt:

Combat trauma is a powerful predictor for a number of mental health problems. PTSD is, of course, the most notable consequence, but veterans who have served in war zones also suffer alarming rates of depression, anxiety and substance abuse. And in recent years, the high suicide rates among U.S. service members have soared to an estimated 22 dying by their own hand each day.

If knowing that isn’t enough to make most Americans – including you – hang their heads, pause in appreciation and potentially cry, I’m not sure what would.

Sadly, veterans with PTSD also have what health care professionals call a “reduced quality of life.” They go to work less and use more health care services.

Unless treated, PTSD typically runs a chronic course and haunts a person for many years or decades. Thus, the substantial burden of PTSD is not just on a veteran’s back, but on their families, their communities and society as well.

The article is here.

When ‘Moneyball’ Meets Medicine

By Jeremy N. Smith
The New York Times
Originally published April 2, 2015

Here is an excerpt:

Now people everywhere can bring “Moneyball” to medicine. A few months after releasing their global numbers in The Lancet, the same scientists supplied the underlying figures for 187 nations. These statistics will be updated again later this year. At last report, in the United States, measured by DALYs, the third-largest health problem was low back pain. Fifth is major depressive disorders. Eleventh is neck pain. Thirteenth is anxiety disorders. None of these maladies kill anyone directly, so they don’t even show up on a list of leading killers. But they still cause huge amounts of pain and suffering, and cost our economy billions of dollars in lost productivity.

When will low back pain get the research funds and attention given to lung cancer, just below it in a DALY ranking? The toll from major depressive disorder, No. 5, is estimated to be 20 percent worse than that from stroke. Why don’t we promote early detection in the same way, on public billboards and ad campaigns? Health loss from anxiety disorders is estimated to be 80 percent higher than that from breast cancer. Do advocates for anxiety treatment even have their own colored ribbon?

The entire article is here.

Mental health workers don't recognise their own burnout

British Psychological Society
Press Release
Originally published January 9, 2015

Some mental health workers find it difficult to recognise their own burnout and even when they do they struggle to admit it to others says a study presented today at the British Psychological Society Division of Occupational Psychology annual conference in Glasgow.

The study was undertaken by PhD student Ms Marieke Ledingham and colleagues Associate Professor Peter Standen (Edith Cowan University, Australia) and Associate Professor Chris Skinner (University of Notre Dame, Australia).

Ms Ledingham explained: “Burnout has long been a problem in mental health workplaces and remains so despite much research and considerable knowledge of it amongst professional employees. Despite working in this sector employees struggle to avoid burnout and we wanted to study how work places could improve support.”

The entire pressor is here.

Medicare considers funding end-of-life talks

By Pam Belluck
The New York Times
Originally published August 31, 2014

Five years after it exploded into a political conflagration over “death panels,” the issue of paying doctors to talk to patients about end-of-life care is making a comeback, and such sessions may be covered for the 50 million Americans on Medicare as early as next year.

Bypassing the political process, private insurers have begun reimbursing doctors for these “advance care planning” conversations as interest in them rises along with the number of aging Americans.

The entire article is here.

Editorial note: Politics will continue to affect health care delivery in the United States.  It is critical that healthcare providers cite foundational ethical principles when advocating for changes in our healthcare system, and not become immersed in sloganeering or bumper sticker politics to support one political party or the other.  High quality health care and informed patient choice are paramount.

Moral responsibility for (un)healthy behaviour

Rebecca C H Brown
Journal of Medical Ethics
J Med Ethics 2013;39:695-698 doi:10.1136/medethics-2012-100774

Abstract

Combating chronic, lifestyle-related disease has become a healthcare priority in the developed world. The role personal responsibility should play in healthcare provision has growing pertinence given the growing significance of individual lifestyle choices for health. Media reporting focussing on the ‘bad behaviour’ of individuals suffering lifestyle-related disease, and policies aimed at encouraging ‘responsibilisation’ in healthcare highlight the importance of understanding the scope of responsibility ascriptions in this context. Research into the social determinants of health and psychological mechanisms of health behaviour could undermine some commonly held and tacit assumptions about the moral responsibility of agents for the sorts of lifestyles they adopt. I use Philip Petit's conception of freedom as ‘fitness to be held responsible’ to consider the significance of some of this evidence for assessing the moral responsibility of agents. I propose that, in some cases, factors outside the agent's control may influence behaviour in such a way as to undermine her freedom along the three dimensions described by Pettit: freedom of action; a sense of identification with one's actions; and whether one's social position renders one vulnerable to pressure from more powerful others.

The entire article is here.

Dementia Rate Is Found to Drop Sharply, as Forecast

By GINA KOLATA
The New York Times
Published: July 16, 2013

A new study has found that dementia rates among people 65 and older in England and Wales have plummeted by 25 percent over the past two decades, to 6.2 percent from 8.3 percent, the strongest evidence yet of a trend some experts had hoped would materialize.

Another recent study, conducted in Denmark, found that people in their 90s who were given a standard test of mental ability in 2010 scored substantially better than people who reached their 90s a decade earlier. Nearly one-quarter of those assessed in 2010 scored at the highest level, a rate twice that of those tested in 1998. The percentage severely impaired fell to 17 percent from 22 percent.

The entire story is here.