I don’t believe I have ever seen the CEO of an oncology facility suggest how doctors should treat those with cancer but the CEO of the Royal Ottawa Mental Health Centre just did in an op ed in the Ottawa Citizen. If the CEO was a psychiatrist I would not object but the author, Joanne Bezzubetz, has an MBA and a PhD in Applied Management and Decision Sciences from Walden University. She has a history of admin positions in mental health but no education in mental health treatment.
She begins by saying that “It is time to put clients (patients) at the centre of their own care, to let them make choices about their therapies, and to give them the resources they need to lead independent and happy lives.”
She is clearly an advocate for patient centred care whereby the health care system puts the needs of the patients first. No one can disagree with that but my question is why is that such a big deal. Without patients, health care personnel have no jobs so what did they do before someone came up with this concept? I hope the system always put the needs of the sick up there at or near the top and always provided them with the treatment and resources they needed to overcome their illnesses, pain and suffering.
None of that should be radical. Where I have a problem is to allow them to make their own choices about treatment. Imagine going to the doctor with an infection and the doctor asking what would you like to do? That doesn’t happen. What the doc does is to present the patient with possible solutions, the pros, the cons, the side effects and then decide on a course with the patient. The choices might be wait and see if it resolves on its own or start antibiotics now.
In oncology, the same process would take place and if the patient decides to not accept conventional treatment but wants to go to Tijuana for alternative therapy, I would expect the doctor to have a long talk with the patient and try to dissuade them. If the patient is adamant then there is not much the doc can do. The patient has the capacity to make that decision and does so.
Under common law, as Justice Robins of the Ontario Court of Appeal explained:
“The right to determine what shall, or shall not, be done with one’s own body, and to be free from non-consensual medical treatment, is a right deeply rooted in our common law. This right underlines the doctrine of informed consent. With very limited exceptions, every person’s body is considered inviolate, and, accordingly, every competent adult has the right to be free from unwanted medical treatment. The fact that serious risks or consequences may result from a refusal of medical treatment does not vitiate the right of medical self-determination. The doctrine of informed consent ensures the freedom of individuals to make choices about their medical care. It is the patient, not the physician, who ultimately must decide if treatment — any treatment — is to be administered.”
What Ms Bezzubetz is espousing is something that already exists and is well entrenched in the legal statutes and in case law. I did highlight With very limited exceptions because it is those exceptions that she may be talking about and those are serious mental illnesses and dementia. It is not unusual for these two groups to be unable to understand that they are ill and to be able to make rational decisions about their care. When it comes to dementia, we mostly understand this and allow a substitute decision maker to make those care decision.
Granny has advanced Alzheimer’s and does not know what day it is, how to make a cup of tea safely but refuses care that will keep her safe. With compassion and understanding, we guide her into the care she needs which may be into a long term care facility where she can be looked after. We do not allow her to wander the streets and to live in the park or at a street corner.
In contrast, a young person with untreated schizophrenia is allowed to refuse treatment because he or she insists there is nothing wrong with them. And the longer their condition is untreated the worse it gets. Their family cannot cope and they end up living on the street, getting in trouble with the law and ending up in jail or dead. Society does not care and seemingly those like Ms Bezzubetz feel that is fine because they were “at the centre of their own care” and were allowed to “make choices about their therapies”.
In Ontario and most other jurisdictions, if these individuals become dangerous to themselves or others, they can be incarcerated in psychiatric facilities. Unfortunately, in Ontario they can still decide upon their treatment which usually is to refuse treatment. As a result, we have patients locked up for years who are dangerous but refuse treatment and the chance to recover and be released. How sensible is that?
If Ms Bezzubetz had more knowledge about psychiatry she would be aware that close to half of all patients with schizophrenia and bipolar disorder do not realize they are ill which is why they refuse treatment. The term is anosognosia and it is not just denial of being ill but a symptom of being ill whereby you are not capable of understanding. The following video by Xavier Amador is a perfect example of this condition.
In addition to or as an extension of this characteristic, people with schizophrenia “experience the world differently. And many have a relatively unique set of cognitive impairments, or problems with their intellectual functioning.” Those with schizophrenia have poor memories, trouble shifting between tasks, making bad judgement calls and failing to predict consequences.
None of this bodes well for them to be able to make rational decisions about treatment or no treatment or the best treatment. At least, of course, in the acute early phase of their illness. In that circumstance, consultation should involve family or those who are closest to the patient and know them best. Once treated and stable, the ill person is capable to discuss refinements in treatment. Physicians should pay attention to potential side effects and be willing to change medications to other drugs or to rationally discuss the choice between oral versus injectable forms of drugs.
Those providing treatment have to have the knowledge and the compassion to treat their patients with the appropriate respect and to act in their best interests.
What I’ve written reflects the frustration of a family member experiencing a health system governed by what I consider the harmful ideas expressed by Ms. Bezzubetz. Part Two tomorrow reflect the experiences of a psychiatrist working within that system.