The patient who refuses medical treatment: a dilemma for hospitals and physicians

This article reviews recent case and statutory law concerning patients who refuse medical treatment. Among the special cases considered are: the competent adult patient who refuses treatment on religious or privacy grounds; the incompetent patient whose own wishes were never expressed, but whose family refuses treatment; the incompetent patient who expressed the wish not to be treated before becoming incompetent; and parents who refuse treatment on behalf of their child. It is pointed out that recent court decisions have blurred the distinctions between "extraordinary" care and "ordinary" care and between withholding and withdrawing life-sustaining treatment. Reference is made to the recent trend toward allowing the family of an incompetent patient to assert the patient's rights without court intervention either in the form of direct court order or through guardianship proceedings. Finally, the implications of these legal developments for health care institutions are discussed. A protocol pertaining to incompetent patients is proposed. Health care institutions are encouraged to develop formal policies for dealing with patients who refuse treatment, and to work with their professional associations in lobbying for legislation which will clarify the law in this area.     

Culture as Values or Culture in Action? Street Codes and Student Violent Offending

ABSTRACT

The authors draw on two competing cultural perspectives—culture as values and culture in action—to examine the relationship between street codes and the propensity to violently victimize others. Specifically, they explore whether individual-level and school-level street codes, net of one another, are related to 3 types of violence: assault, robbery, and sexual battery. In addition, they consider whether these effects vary according to 3 contextual characteristics: (a) the location of the offending—in school versus out of school, (b) school-level economic disadvantage, and (c) school efficacy. Three-level ordinal logistic regression models are estimated using four waves of survey data from over 3,000 students nested within 103 schools. Results provide evidence that individual-level street codes are related to violent offending in a manner that is, largely speaking, not tied to context. However, there is some evidence that the effects of school-level street codes on offending differ between outside of school and in school settings and are conditioned by levels of school disadvantage and efficacy. Overall, some support is offered for both the culture-as-values and culture-in-action perspectives.     

Family Representative Payeeship and Violence Risk in Severe Mental Illness

Although representative payeeship is prevalent among people with mental illness and shows promise to positively influence clinically relevant outcomes, research also suggests this legal mechanism could be implemented in ways that are problematic. The current study examined whether family representative payeeship was associated with elevated risk of family violence perpetrated by persons with severe mental illness (SMI). Data were collected every 4 months for 1 year in structured interviews with N = 245 persons with SMI who received disability benefits. Multivariate analyses showed that substance abuse, history of violence, frequency of family contact, and family representative payeeship were associated with elevated odds of family violence. Analyses also showed family contact and family representative payeeship had a cumulative effect on increasing the predicted probability of family violence (controlling for covariates such as violence history and substance abuse). The data shed light on the potential for family representative payeeship to be associated with increased risk of interpersonal conflict and violence in SMI.     

Does involuntary outpatient commitment lead to more intensive treatment?

Studies of involuntary outpatient commitment (OPC) among persons with severe mental illness have concluded that OPC is only effective in improving treatment outcomes when it is sustained for 6 months or longer and is combined with frequent outpatient services. This article explores factors that influence the delivery of outpatient services to subjects in a randomized trial of OPC and finds 2 general patterns. Outpatient visits were more frequent among all subjects with apparent clinical need, regardless of study assignment, and among subjects whose OPC was sustained beyond an initial court order. These results suggest that, in practice, sustained OPC represents a consensual agreement between clinicians and the court to more intensively address the complex needs of persons with severe and persistent mental illness.     

Screening for severe mental disorder in jails

Despite the demonstrated prevalence of severe mental disorder among jail detainees and the legal mandate to provide mental health services, most jails do not have the resources to incorporate traditional, time-consuming psychological assessment techniques into their routine intake process. As a result, a number of mentally ill jail detainees remain undetected and untreated. This study outlines the development of the Referral Decision Scale (RDS), which detects persons who have a high probability of having a severe mental disorder so that they can be given a complete diagnostic evaluation. The 14-item RDS was statistically derived using discriminant analysis from data collected via the NIMH Diagnostic Interview Schedule on 728 randomly selected male jail detainees and then validated on 1,149 prison inmates. The final validated version of the RDS had an overall sensitivity of 0.791, specificity of 0.987, and positive and negative predictive value of 0.791 and 0.013, respectively. Since these statistics far exceed current detection rates, the RDS is likely to facilitate the diversion of mentally ill detainees in situations where it is impractical to administer psychological examinations to all incoming inmates. Training requirements for the RDS and directions for future research are discussed.This research was supported in part by National Institute of Mental Health under grant No. R01MH37988. We would like to thank Karl Kilgore, Stuart Michaels, John Lyons, Karen Abram, Richard White, and Christine Davidson for their statistical insights and helpful comments. James Collins is due special thanks for making his North Carolina prison data available. We are also grateful to Philip Hardiman, Thomas Monahan, and Ronald Simmons for their cooperation with the data-collection process.     

Long-term care: common issues and unknowns

All industrialized countries are grappling with a common problem—how to provide assistance of various kinds to their rapidly aging populations. The problem for countries searching for models of efficient and high-quality long-term care (LTC) policies is that fewer than a dozen countries have government-organized, formal LTC policies. Relatively new surveys focused on the elderly populations of about 25 countries could become the basis for research on which LTC policy design choices have desired outcomes for individuals and society and might be replicable in other countries. As in earlier decades when U.S. researchers created the Current Population Survey (CPS) modules and the Survey of Income and Program Participation to answer policy questions, researchers and policy analysts are now at a point where a concerted effort is needed to generate questions that international comparative research on LTC could answer as well as the data needed to address the questions.     

Influences of Childhood Abuse on Parenting Perspectives of Pregnant Cohabitors

Using thematic analysis, we examine the effects of childhood abuse regarding parenthood for pregnant cohabitors from qualitative interviews. Participants (N?=?18; 10 women and 8 men) recalled childhood abuse during the Adult Attachment Interview. Three themes emerged: (1) “Learning what not to do,” whereby abuse is discussed as something not to continue, and harmful toward children; (2) “Use but modify parents’ discipline,” whereby individuals state that they will employ methods of their parents, but in ways different for their children; and (3) “Ambiguous,” whereby discussions are unclear and confused about how the abuse will affect their parenting. These results suggest that even when pregnant cohabitors want to parent differently than their own parents, they may not have relevant models or skills. For practitioners, we suggest interventions aimed at providing alternative models for how to parent, and effective and appropriate disciplining methods, as ways to deter intergenerational abuse.