We describe the legal practice of using civil court orders to mandate outpatient mental health treatment for adults with serious mental illness. After briefly placing the practice in historical context, we discuss the traditional clinical rationale and assumptions underlying outpatient commitment and its legal variants, as well as how the predominant and controversial preventive form of outpatient commitment emerged in the U.S. to address limitations of earlier versions of these laws, such as "conditional release." We then consider whether, and under (...) what conditions, outpatient commitment may be ethical, and we provide a conceptual framework for deciding such questions at the policy and individual-case levels. (shrink)

In the context of long waiting time to access rehabilitation services, a large majority of settings use referral prioritization to help manage waiting lists. Prioritization practices vary greatly between settings and there is little consensus on how best to prioritize referrals. This paper describes the prioritization processes for physiotherapy services in Québec and its potential implications in terms of equity in access to services. This is a secondary analysis of a survey of outpatient physiotherapy departments (n=98; proportion of participation was (...) 99%) conducted in 2015 across publicly funded hospitals in Québec. In many settings, persons with acute orthopaedic conditions were prioritized while chronic conditions were given a lower priority. There were 72 different combinations of prioritization criteria used in outpatient physiotherapy departments. Variability was also observed in the type of personnel involved in the prioritization process, the number of priority levels used to rank the referrals and the source of information used to prioritize referrals. These results highlight potential issues regarding equity in access to physiotherapy services: the prioritization of persons with acute conditions to the detriment of those with chronic conditions, the lack of consensus on a fair prioritization process and the importance to adequately assess patients’ needs for treatment. Further research and interventions on prioritization criteria and processes are needed to ensure equitable access to physiotherapy services, especially in the public sector. (shrink)

In the context of long waiting time to access rehabilitation services, a large majority of settings use referral prioritization to help manage waiting lists. Prioritization practices vary greatly between settings and there is little consensus on how best to prioritize referrals. This paper describes the prioritization processes for physiotherapy services in Québec and its potential implications in terms of equity in access to services. This is a secondary analysis of a survey of outpatient physiotherapy departments conducted in 2015 across publicly (...) funded hospitals in Québec. In many settings, persons with acute orthopaedic conditions were prioritized while chronic conditions were given a lower priority. There were 72 different combinations of prioritization criteria used in outpatient physiotherapy departments. Variability was also observed in the type of personnel involved in the prioritization process, the number of priority levels used to rank the referrals and the source of information used to prioritize referrals. These results highlight potential issues regarding equity in access to physiotherapy services: the prioritization of persons with acute conditions to the detriment of those with chronic conditions, the lack of consensus on a fair prioritization process and the importance to adequately assess patients’ needs for treatment. Further research and interventions on prioritization criteria and processes are needed to ensure equitable access to physiotherapy services, especially in the public sector. (shrink)

It is not the outpatient setting, per se, that is presenting new challenges and opportunities to ethics consultants and ethics committees. Rather, it is the underlying reason for shifting more and more patient care from the inpatient to the outpatient setting-namely, calculations of cost-effectiveness.

ObjectiveTo assess the impact of the closure of group-based cardiac rehabilitation training during the first COVID-19 lockdown in spring 2020 on patients’ physical activity, cardiorespiratory fitness, and cardiovascular risk, and to describe the patient experience of lockdown and home-based exercise training during lockdown.DesignMixed methods study. Prospectively collected post-lockdown measurements were compared to pre-lockdown medical record data. Quantitative measurements were supplemented with qualitative interviews about the patient experience during lockdown.SettingOutpatient CR centre in Salzburg, Austria.ParticipantsTwenty-seven patients [six female, mean age 69 years] (...) who attended weekly CR training sessions until the first COVID-19 lockdown in March 2020.Outcome MeasureQuantitative: exercise capacity, cardiovascular risk. Qualitative: individual semi-structured interviews.ResultsExercise capacity had significantly reduced from pre- to post-lockdown: mean power in maximal ergometry 165 vs. 151, p < 0.001; submaximal ergometer training 99 vs. 97, p = 0.038. There was no significant difference in Framingham risk score and other cardiovascular risk factors. Qualitative data showed that almost all patients had kept physically active during lockdown, but 17 said they had been unable to maintain their exercise levels, and 15 felt their cardiorespiratory fitness had deteriorated. Many patients missed the weekly CR training and the motivation and sense of community from training together with others. Several patients stated that without professional supervision they had felt less confident to carry out home-based exercise training at high intensity.ConclusionThis study highlights the importance of group-based supervised exercise training for patients who engage well in such a setting, and the detrimental impact of disruption to this type of CR service on physical activity levels and exercise capacity. Additionally, learning from the COVID-19 pandemic may inform the development and implementation of remote CR modalities going forward. (shrink)

At 41 weeks, the patient had been delivered by Cesarean section for failure to progress at Hospital A in the same city. Three days after birth she suffered a respiratory arrest. Resuscitation and ventilator support were initiated promptly but the child did poorly, and shortly after this first arrest, the parents were told by the child's physician that she had no chance of recovery. Nevertheless, the mother continued to insist that the child be kept on a respirator and aggressive support (...) be maintained. (shrink)

The association of resilience-related factors with frailty is a recent research topic. Dispositional optimism and context sensitivity are two psychological factors that differently contribute to individual resilience. This study aimed at investigating whether dispositional optimism and context sensitivity might contribute to a multifactorial model of frailty, together with established relevant factors such as cognitive and physical factors. This cross-sectional study involved 141 elderly outpatients aged ≥65 years, who were referred to the Geriatrics and Multidimensional Evaluation Clinic of the University (...) Hospital of Messina. We used the following measures: the Mini-Mental State Examination to screen for global cognitive functioning; 4-m gait speed and handgrip strength to measure physical performance; a 35-item Frailty Index to evaluate patients’ frailty status; the revised Life Orientation Test to gauge dispositional optimism; and the Context Sensitivity Index to measure context sensitivity. We found that LOT-R, CSI, and MMSE were all significantly associated with FI. Gait speed was only marginally associated with FI. The present study showed a novel association of dispositional optimism and context sensitivity with frailty among elderly outpatients. These preliminary findings support a multidimensional approach to frailty in which even peculiar psychological features might provide a significant contribution. (shrink)

In mental health policy, a central ethical dilemma concerns involuntary outpatient commitment (OPC), which aims to treat vulnerable individuals with serious mental illness who decline services. The first concern regards whether coercive services undermine the quality of clinical interactions within treatment, particularly as it relates to psychiatric medication use. The second concern is the unexamined role that OPC, and coercive psychiatric programs more broadly, play in the broader landscape of social welfare policy. To examine these concerns, the purpose of this (...) dissertation is to analyze how the management of psychiatric medications in involuntary outpatient services is undergirded by (a) provider and client interpretations of psychiatric medication effects and (b) moral discourses related to coercion and client autonomy. To achieve this aim, I examined data from a team-based ethnography that consisted of 1000 hours of participant observations and 56 semi-structured interviews with 20 clients, 21 providers, and 12 client family members with diverse backgrounds. I analyzed how medication compliance was discussed, monitored, and enforced in an involuntary outpatient program. My analysis demonstrates that medications were interpreted as a technology to control clinical symptoms (clinical control) though, particularly among clients, were also viewed as a method to control client mental experiences, behavioral expression, and autonomy (social control). Providers believed that medications were a necessary component of services (compulsory compliance) and could reduce client vulnerability to violence victimization and perpetration related to clinical symptoms (medicating vulnerability). To address client noncompliance, providers employed several strategies that I categorized as client manipulation. These strategies included providers, family members, and court officials strategizing ways to undermine client autonomy without clients’ knowledge (concealed collusion), deceiving clients into believing that medications were mandated when they were not (performing coercion), and minimizing the role of client consent and preferences in decision-making processes (circumventing consent). These findings demonstrate the pervasive role of manipulation to gain client medication compliance in OPC, which I named institutional coercion. They also highlight that the broader moral justifications for manipulating clients relate to their status as structurally vulnerable in their community settings and a growing relationship between the erosion of the welfare state and psychiatric coercion. (shrink)

The first aim of the study was to identify when deliberate self-harm behavior ceased in patients with borderline symptoms undergoing dialectical behavioral treatment. The second aim was to compare patients who ceased their self-harm behavior early or late in the course of treatment, with regard to demographics, comorbidity, and symptom severity. The study used a naturalistic design and included 75 treatment completers at an outpatient DBT clinic. Of these 75 patients, 46 presented with self-harming behavior at pre-treatment. These 46 participants (...) where split into two groups, based on median amount of time before ceasing self-harm behavior, termed early and late responders. Treatment duration varied from 16 to 160 weeks. Patients were assessed pre- and post-treatment using measures of depression, hopelessness, personality traits, quality of life, and global assessment of symptoms and functioning. The majority ceased their self-harming within the first year, and the average number of weeks was 15.5. Twenty-five percent of patients ceased their DSH behavior during the first week of treatment. For the remaining patients, the cessation of DSH continued gradually across a 1 year period. We found no differences between early and late responders with respect to demographics, comorbidity, symptom severity, or treatment outcome. None of the patients committed suicide. The findings indicate that self-harming behavior decreases gradually across the first year after starting DBT. (shrink)

Justifying involuntary psychiatric treatment on the basis of a judgment that a person lacks capacity is usually expressed in terms of a person’s ability to make a decision about his or her health and treatment. Typically, this relates to the ability to refuse treatment. Exactly what “capacity” means, however, and how one determines when another individual lacks capacity, or lacks sufficient capacity, in this context is particularly controversial, with the United Nations Committee on the Rights of Persons with Disabilities insisting (...) that involuntary treatment be abandoned altogether and capacity tests avoided.Capacity is a concept that has multiple meanings and applications across different disciplines and... (shrink)

Refining the model for an emergency department‐based mental health nurse practitioner outpatient service The mental health nurse practitioner (MHNP) role based in the emergency department (ED) has emerged in response to an increase in mental health‐related presentations and subsequent concerns over waiting times, co‐ordination of care and therapeutic intervention. The MHNP role also provides scope for the delivery of specialised primary care. Nursing authors are reporting on nurse‐led outpatient clinics as a method of healthcare delivery that allows for enhanced access (...) to health‐care, particularly following hospital discharge. However, due to a lack of in‐depth substantiation, this mode of service delivery requires more thorough investigation. This study describes the refinement phase undertaken before the implementation and pilot evaluation of a formalised and structured MHNP outpatient service in the ED of a large inner‐city hospital in Sydney, Australia. An expert advisory panel (EAP) consisting of key local informants was convened to provide feedback on and refinement to the proposed model. This related to issues such as target population, structure and process considerations, outcome measures and interface within the overall health service. Findings from the EAP meeting are presented and discussed. The importance of linking methods with the appropriate methodology in evaluating a healthcare program is highlighted. (shrink)

Background Compulsory treatments represent a legal means of imposing treatment on an individual, usually with a mental illness, who refuses therapeutic intervention and poses a risk of self-harm or harm to others. Compulsory outpatient treatment in psychiatry, also known as community treatment order, is a modality of involuntary treatment that broadens the therapeutic imposition beyond hospitalization and into the community. Despite its existence in over 75 jurisdictions worldwide, COT is currently one of the most controversial topics in psychiatry, and it (...) presents significant ethical challenges. Nonetheless, the ethical debate regarding compulsory treatment almost always stops at a preclinical level, with the different ethical positions arguing for or against its use, and there is little guidance to support for the individual clinicians to act ethically when making the decision to implement COT. Main body The current body of evidence is not clear about the efficacy of COT. Therefore, despite its application in several countries, evidence favouring the use of COT is controversial and mixed at best. In these unclear circumstances, ethical guidance becomes paramount. This paper provides an ethical analysis of use of COT, considering the principlist framework established by Ross Upshur in 2002 to justify public health interventions during the 2002–2004 severe acute respiratory syndrome outbreak. This paper thoroughly examines the pertinence of using the principles of harm, proportionality, reciprocity, and transparency when considering the initiation of COT. Conclusion Ross Upshur’s principlist model provides a useful reflection tool for justifying the application of COT. This framework may help to inform sounder ethical decisions in clinical psychiatric practice. (shrink)

Studies link involuntary outpatient commitment with improved patient outcomes, fueling debate on its ethical justification. This study compares inpatient utilization for committed outpatients in the 1990s with those who were not under outpatient civil commitment orders. Findings reveal committed outpatients had higher utilization of inpatient services and restraint episodes prior to their commitment compared with a control group. Committed outpatients also were more likely to have been on discharge status at the time of admission, have been admitted (...) involuntarily under emergency legal procedures, and have had a greater number of admissions and hospital days prior to their commitment. Following commitment, patients had fewer hospitalizations, shorter lengths of stay, fewer seclusion episodes and hours, and fewer restraint episodes and hours. Findings are discussed within the context of parens patriae and therapeutic jurisprudence, and support medical and public policy justifications for ethical uses of outpatient civil commitment laws for seriously mentally ill patients. (shrink)

Objective: To investigate the prevalence of and risk factors associated with mental health symptoms in psychiatric outpatients and their family members in China during the COVID-19 pandemic.Methods: This cross-sectional, survey-based, region-stratified study collected demographic data and mental health measurements for depression, anxiety and acute stress from 269 psychiatric patients and 231 family members in the Second Xiangya Hospital in China from April 27, 2020 to May 8, 2020. Binary logistic regression analysis was performed to identify risk factors associated with (...) mental health outcomes.Result: The results of this survey revealed that symptoms of depression, anxiety, and acute stress were highly prevalent symptoms in the psychiatric patient group. Respondents who were female, unmarried or highly educated were significantly more likely to have the above symptoms. In the family member group, more than half of them felt that the burden of nursing had increased during the epidemic. Subjects with a high degree of burden of care were significantly more likely to exhibit the above mental health symptoms, while females were significantly more likely to have acute stress.Conclusions: The results of this survey revealed a high prevalence of mental health disorder symptoms among psychiatric patients and an increased burden of nursing among their family members after the COVID-19 outbreak in China. Understanding the risk factors in those particular groups of people help improve the public health service system for mental health problems during public health events. For further study, exploration of the needs of mental health services and dynamic change tracking will be needed. (shrink)

Studies link involuntary outpatient commitment with improved patient outcomes, fueling debate on its ethical justification. This study compares inpatient utilization for committed outpatients in the 1990s with those who were not under outpatient civil commitment orders. Findings reveal committed outpatients had higher utilization of inpatient services and restraint episodes prior to their commitment compared with a control group. Committed outpatients also were more likely to have been on discharge status at the time of admission, have been admitted (...) involuntarily under emergency legal procedures, and have had a greater number of admissions and hospital days prior to their commitment. Following commitment, patients had fewer hospitalizations, shorter lengths of stay, fewer seclusion episodes and hours, and fewer restraint episodes and hours. Findings are discussed within the context of parens patriae and therapeutic jurisprudence, and support medical and public policy justifications for ethical uses of outpatient civil commitment laws for seriously mentally ill patients. (shrink)

BackgroundThe principles of informed consent, confidentiality and privacy are often neglected during patient care in developing countries. We assessed the degree to which doctors in Lahore adhere to these principles during outpatient consultations.Material & MethodThe study was conducted at medical out-patient departments (OPDs) of two tertiary care hospitals (one public and one private hospital) of Lahore, selected using multi-stage sampling. 93 patients were selected from each hospital. Doctors' adherence to the principles of informed consent, privacy and confidentiality was observed through (...) client flow analysis performed by trained personnel. Overall patient perception was also assessed regarding these practices and was compared with the assessment made by our data collectors.ResultsSome degree of informed consent was obtained from only 9.7% patients in the public hospital and 47.8% in the private hospital. 81.4% of patients in the public hospital and 88.4% in the private hospital were accorded at least some degree of privacy. Complete informational confidentiality was maintained only in 10.8% and 35.5% of cases in public & private hospitals respectively. Informed consent and confidentiality were better practiced in the private compared to the public hospital (two-sample t-test > 2, p value < 0.05). There was marked disparity between the patients' perspective of these ethical practices and the assessment of our trained data collectors.ConclusionObservance of medical ethics is inadequate in hospitals of Lahore. Doctors should be imparted formal training in medical ethics and national legislation on medical ethics is needed. Patients should be made aware of their rights to medical ethics. (shrink)

This book is a resource for providers and students, integrating germane basic science information with clinical-medicine insights. The goal is to improve primary-care outpatient interactions for physicians, APRNs, and PAs. It is unique, integrating germane basic-science information with clinical-medicine. Unlike other resources that introduce these concepts more distinctly, this book bridges the gap and provides insights for providers and students. Also, there are succinct, yet comprehensive, presentations on managing the more common out-patient problems. The book is designed for primary care (...) providers and students, e.g., physicians, APRNs, and PAs, who desire to improve their patient-education, diagnostic, and treatment skills. The PEARLS are instruments to embellish and emphasize important concepts. The focus of the book is to improve outpatient medicine delivery, and better informed and confident providers are keys to the process. (shrink)

Many academic medical centers are seeking to attract patients from outside their historical catchment areas for economic and programmatic reasons, and patients are traveling for treatment that is unavailable, of poorer quality, or more expensive at home. Treatment of these patients raises a number of ethical issues including whether they may be given priority in scheduling outpatient follow-up appointments in order to reduce the period of time they are away from home. Granting them priority is potentially unjust because medical treatment (...) is generally allocated based on medical need and resource utilization, and then on a first-come, first-served basis. While it is difficult to compare the opportunity cost of waiting for an appointment to different patients, nonresident patients incur higher expenditures for travel, room, and board than resident patients. Giving them priority in scheduling to reduce these costs may be justifiable. Preferentially scheduling nonresident patients may also indirectly benefit resident patients consistent with Rawls’s difference principle. This potential justification, however, rests on several empirical claims that should be demonstrated. In addition to reducing resident patients’ waiting times, medical centers should not prioritize nonresident patients over resident patients with more urgent medical needs. There is, therefore, a limited and circumscribed justification for prioritizing nonresident patients in scheduling follow-up appointments. (shrink)

This article analyzes doctor–patient communication at admission interviews in an outpatient mental health care service at a public hospital in Buenos Aires, Argentina. These interviews are the first contact between professionals and patients, and they result in the admission or rejection of the latter into the medical institution. In particular, we observe how context, understood as a sociocognitive and scalar concept, is reshaped with gaze direction and agenda-setting through interaction, resulting in three hierarchical spaces which can be represented as degrees (...) in a scale: the public, the private, and the intimate level. This description will allow us to understand a series of communicative difficulties that may result from scale maladjustments, in which professionals interact with patients at different levels and therefore cannot give adequate feedback to satisfy mental health care needs. (shrink)

ObjectiveThis study aimed to better understand the current situation involving work stressors and the coping styles of outpatient and emergency nurses in 29 pediatric specialty hospitals across China. The study analyzed this correlation to provide a reference for the occupational stress management of pediatric nurses.MethodsFrom June to September 2020, 1,457 outpatient and emergency nurses in 29 pediatric specialty hospitals across China were selected as study participants, and a questionnaire survey was conducted using the Basic Information Questionnaire, the Chinese version of (...) the Work Stressor Scale for Nurses, and the Simple Coping Style Scale.ResultsThe assessed stress level of outpatient and emergency nurses in 29 tertiary pediatric specialty hospitals nationwide is lower than the results of the survey of the 2007 domestic norm, p < 0.05. The stressors related to nurses’ expectations, family conflicts, the nature of nursing work, patient factors, and workload were lower compared with the national norm. The positive coping style score on the Simple Coping Style Scale for pediatric outpatient nurses was, and work stressors were positively associated with negative coping styles. Multiple regression analysis showed that the influencing factors of work stressors among pediatric outpatient and emergency nurses correlated with the authorized size, age, working years of nurses, work department, and negative coping styles.ConclusionNegative coping styles were present among pediatric outpatient and emergency nurses and were associated with work stressors. The influencing factors of stressors mainly correlated with the clinical establishment, age, years of employment as a nurse, work department, and negative coping styles. (shrink)

Introduction: Consultation methods differ between medical practitioners depending on the individual setting. However, the central tenet to the doctor–patient relationship is the issue of confidentiality. This prospective survey highlights patient attitudes towards consultation methods in the setting of an ophthalmic outpatient department. Method: Questionnaires were completed by 100 consecutive patients, who had been seen by an ophthalmologist in a single room, which had a joint doctor–patient consultation occurring simultaneously. Results: Each question of all 100 questionnaires was completed. 58% of patients (...) were not concerned about sharing a consultation room with another patient or doctor. However, this did not equate to the 49% of patients who were indifferent to discussing issues in the joint consultation room. The most common factor was the general issue of confidentiality. Discussion: Ensuring total patient confidentiality may be deemed more necessary for certain medical specialties than for others, as seen in the practice of separate medical records in genitourinary medicine, for instance. However, with regard to patient consultations, the same level of confidentiality should be afforded across all specialties, and such factors should be borne in mind when planning outpatient clinics. (shrink)

Families of children with mental health challenges may have been particularly vulnerable to emotional distress during the COVID-19 pandemic. This cross-sectional study surveyed 81 parents of children ages 6–17 years receiving mental health treatment in an outpatient clinic during the pandemic. We sought to characterize the impact of the pandemic on family relationships and parental well-being. Additionally, regression and ANCOVA models examined associations between four potentially protective factors—parents’ psychological resilience, perceived social support, positive family experiences during the pandemic, and children’s (...) use of cognitive or behavioral coping strategies—with family relationships and parental well-being. Findings suggest that families of children with mental health conditions experienced remarkable challenges to family relationships, parental well-being, and parents’ perceived capacity to support their children’s mental health. Nearly 80% of parents reported a negative impact of the pandemic on their own well-being, and 60% reported reduced ability to support their children’s mental health. Simultaneously, protective factors appeared to mitigate the negative impact of the pandemic. Particularly, support within the family and from external sources were associated with better self-reported well-being for parents and their capacity to support their children. Children’s use of coping tools, likely enhanced by mental health treatment, was also positively related to better family relationships and parental ability to support children with mental health challenges. Our findings highlight the need for enhancing supports for families at multiple levels including individual skill-building, family-based/parenting support, and community-based support. (shrink)

This article presents the results of a study in The Netherlands among two groups of religious people: i.e., 165 Christian outpatients and 171 parishioners. In this study, we focused on the following main questions. To what degree did these two groups of Christians practice positive religious coping, negative religious coping and receptive coping? What are the relationships between these three coping strategies? To what degree were positive religious, negative religious and receptive coping activities related to the well-being of the (...) respondents? What are the best predictors of well-being: positive religious, negative religious or receptive coping? The results showed that positive religious, negative religious and receptive coping were three independent predictors of well-being, with negative religious coping being the best predictor. (shrink)

Background: Midwives are required to make ethical decisions with the support of respective codes of professional ethics which provide a framework for decision making in clinical practice. While each midwife should be ethically aware and sensitive to the ever-changing issues within reproduction, few empirical studies have examined the views of student midwives in relation to reproductive ethical dilemmas. Objective: The aim of this study was to explore midwifery students’ reactions to a number of ethical dilemmas relating to women’s experiences of (...) reproductive decision making. Design: A series of focus groups were conducted with midwifery students who were asked to discuss five culturally significant scenarios including issues of knowledge acquisition regarding methods of family planning, removal or insertion of an intrauterine device, and abortion. Setting: A University in Turkey was the setting for this study. Participants: Purposeful sampling was adopted which resulted in five focus groups with a total of 57 midwifery students. Ethical considerations: The study was reviewed and granted formal ethical approval by an ethical committee at the Faculty of Health Science in Atatürk University. The head of the Faculty of Health Science approved the investigation. The participants received both oral and written information about the study and they gave their consent. Results: Five themes were identified from the analysis of the focus group data related to all five scenarios. These themes were ‘the right to information’, ‘choice and protection’, ‘parental rights and welfare of the women’, ‘make a decision’ and ‘women rights and sexual abuse’. Conclusion: This study has shown that while students respected women’s choice, they also expressed great ambivalence in some situations when personal values conflict with dominant societal beliefs and professional ethics. A focus on ethics education to include human rights is suggested as a means to enable students to explore their own social-value judgements, and as a means to limit the possible development of ethical confusion and moral distress. (shrink)