Prelude: Rita is a registered nurse with advanced expertise in psychiatric ward, and she works as a member of a multidisciplinary team looking after Treatment
Prelude: Rita is a registered nurse with advanced expertise in psychiatric ward, and she works as a member of a multidisciplinary team looking after Treatment Resistant Depression (TRD) patients. Rita oversees patients discharge from the hospital. Prof S, the leader of her team, heavily relies on her reports before making discharge decisions. Mr R, one of her patients, died by suicide when he jumped from the 8th floor of an hotel adjacent to the hospital, after having been discharged. Mr R’s family raised several concerns about his treatment to the Coroners Court. These included: • Appropriateness of the qualifications of the treating nursing team and their assessments of Mr R and role in the decision to discharge Mr R from Hospital; • A lack of an appropriate consent process for the implantation of a Deep Brain Stimulator1 technology (DBS) and particularly, a failure to advise Mr R that suicide and reversible changes in mood/personality were risks associated with DBS surgery; • Lack of communication by the clinicians with Mr R’s family; • Post-operative DBS complications; • Management of his physical concerns in Hospital; • The management of his mental health; • The death could have been avoided had his medical advice and treatment been different. Case: Mr R, a twenty-seven-year-old patient, received the diagnostic of depression when aged fifteen. When Rita first met Mr R, he self-reported more than 30 ineffective and/or poorly tolerated medication trials and an ineffective course of electroconvulsive therapy which have lead him to seek last recourse treatment. During their first meeting, Rita suggested to Mr R to consider the possibility of enrolling in a new experimental DBS trial for TDR, where she sits as co-researcher with multiple colleagues, under the leadership Prof S. One week following Rita first meeting with Mr R, he consulted Prof S to undergo an experimental usage of DBS targeting TRD. During the consultation, Mr R was accompanied by his brother. Prof S advised Mr R that DBS was an experimental treatment potentially targeting TDR symptoms. Prof S says that he advised Mr R that the potential risks of the DBS surgery include death, permanent disabling stroke, infection of the brain or the IPG, seizure disorder, and reversible changes in mood/personality. Mr R was also told that DBS therapy 1 DBS surgery involves implanting a thin, insulated lead into the brain (most often in the subthalamic nucleus or the globus pallidus, which are part of the basal ganglia system.) The lead is then connected via an insulated extension to a device called an implanted pulse generator (‘IPG’). This is similar to a pacemaker. The extension runs below the skin from the head down the side of the neck behind the ear to the IPG which is usually implanted under the skin in the chest. When switched on, the IPG produces electrical impulses that are sent to the brain. The impulses can be adjusted using a patient programmer. 2 | Page may not his symptoms. However, retrospectively, Mr R’s brother disputes that Mr R was told about reversible changes in mood and personality. The informed consent signed by Mr R stipulated: “The doctor may […] withdraw you from trial at any time if he/she considers this to be in your best interest.” The surgery was performed without incident one month later, it was uneventful, and Mr R’s surgical wounds healed well. Mr R had inserted bilateral stimulators within the subcallosal cingulate cortex. Thursday, one day after the surgery, Mr R indicated to Rita that he experienced some headache, and commented “I feel like I am who I am now, but it’s not the me that went into the surgery.” These feelings of self-estrangement were experienced with suicidal thoughts and that for the past day Mr R had thought about nothing else but ending things. He reported wanting to make sure it was permanent and that this was the only reason he had not acted on his thoughts. Accordingly, Rita indicated in her records a number of sources for the distress, including: • Mr R was experiencing severe pain as a feature of his brain surgery. This was not well controlled as his DBS device which had only recently been reactivated and was not yet functioning at optimal levels. Rita’s impression was that Mr R presented with a mixture of dysphoric/depressive and hypomanic symptoms. She suspected the DBS stimulation may be contributing to hypomania. The following morning, Mr R was seen by Prof S who increased his DBS voltages. That afternoon, Rita noted Mr R was “very upset and agitated.” He was upset that his voltages weren’t “tweaked earlier”. Rita explained that he might not necessarily be adjusted every day. Mr R admitted that his TDR’s symptoms were not too bad yet but was anxious for further adjustment. He was unsure if the DBS or the stress was causing his mood problems. The weekend things were stable. However, the brother of Mr R left a voice message to Rita at work, informing her “I don’t recognise my brother since the surgery. He uncharacteristically seems so impulsive and appears always changing his mind”. When assessing Mr R on Monday his primary complaint to Rita was a “twisting” pain in his head. Mr R associated the pain with increased stimulation and the morning dose of medications. He told Rita he had a return of agitated mood over the weekend, experience of self-estrangement and suicidal thoughts. Rita wrote in her report that the suicidal thoughts were a result of the pain Mr R was experiencing. Given the severe adverse affects, removal of the device was prescribed by the treating team based on the belief that no therapeutic benefit would accrue from further treatment. Despite absence of any benefit from the trial and the severity of suicidality, Mr R formally refused, opposed, and resisted the device removal. 3 | Page Tuesday, Rita noted that Mr R had a better day but his pain remained troublesome. He had no agitation or suicidal thoughts. Mr R remained fixated on his postoperative course / device settings. Rita noted improvement in mood although there were some remaining issues: • sensitivity to stimulation (agitation, mood changes); • uncertainty regarding his discharge location (currently expressing clear preference to live independently in Sydney rather than with his brother). Eight days after surgery, Rita reviewed Mr R and noted his mood was improved and he had no suicidal thoughts, which according to her demonstrated stability from a mood perspective. He described one brief episode of mood deterioration two days prior, however this was not associated with suicidal thoughts. Rita developed a plan for discharge with Mr R, and discussed this with his brother who insisted it was premature to discharge his brother from the Hospital, despite Mr R stating he was happy with his mood. Rita’s report was sent to Prof S. Mr R was discharged that very same day. . Two days later, Mr R’s brother dropped Mr R off at the front of the Hospital and saw him go inside the administration area. Mr R did not go to the Hospital but instead checked into the Summit Apartments, an adjacent hotel to the Hospital. This occurred at approximately 10:20am. Around 11h30, Mr R’s brother received a text message from Mr R. This text message suggests that: • Mr R’s main concern was his pain; • Mr R considered he was put back on TRD’s medication without appropriate supervision and proper pain control; • The treating team did not believe him or properly listen to him; • If the possibility of such pain had been explained to him, he may not have had the operation; and • His death could have been prevented had his medical advice and treatment been different. Just after 11.30am, an eyewitness reported seeing Mr R jumped from the balcony of his room (8th floor). The discussion board forum will be moderated. Here are further details about Assessment Task 1: Discussion posts (online):
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