Systems Interventions and Ethical Considerations

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The above treatment approaches are aimed at the factitious disorder patient. In the broader context, it is also important to include the system treating the patient in any therapeutic interventions. Once a diagnosis of factitious disorder is made or even suspected, it is appropriate for the primary medical team to obtain psychiatric consultation. The psychiatric consultant can help the team evaluate the psychiatric information the patient provides to see if it is consistent with a factitious disorder. In addition, once a firm diagnosis of factitious disorder is made, the psychiatrist plays a key role in the caregiving system.

It is natural for the medical and nursing staff to react with anger and a sense of betrayal toward factitious disorder patients. The patient, who as part of the societal sick role was supposed to be honest with caregivers and want to recover, is now regarded as an antagonist. It is important for the staff members to explore and ventilate their natural feelings of anger toward the patient. The psychiatrist can play an important role by serving as a leader of a group support meeting in which these feelings can be expressed. If these feelings are not dealt with in this manner, the staff may act out their feelings in some other way (e.g., through premature discharge or through inappropriate medical decisions). The psychiatrist can also educate physicians and nurses about the concept of factitious disorders. This often allows the staff to view the patient with less anger and more appropriately as having a serious psychiatric disorder. The staff meeting also allows for clear intrastaff communication; this is important because factitious disorder patients tend to split staff into opposing factions. Staff meetings often develop the following management guidelines:

• One primary physician should direct all care and consultations for the patient.
• Invasive tests or procedures should be done only after positive signs indicate that they are necessary.
• The primary physician should have regular visits with the patient so that the patient does not need to invent new symptoms to see the primary physician.
• The primary physician should encourage self-management.
• The primary physician should positively reinforce healthy behaviors.
• Comorbid conditions such as depression should be treated.

Staff meetings are also useful settings for the consideration of ethical issues raised in connection with factitious disorders, some of which directly impinge on the treatment of the disorder:

• Are investigations to discern the true cause of a patient’s illness an invasion of privacy when they include room searches without the patient’s consent?
• Is it appropriate for the discovering physician to communicate the factitious disorder diagnosis to the referring physician if the patient does not authorize the release of information?
• Does the patient have the usual rights of a patient-doctor relationship, or has the patient abrogated them by his or her duplicity?
• Should patients with factitious disorders be regarded as suicidal and thus be considered for involuntary psychiatric hospitalization?
• Should factitious disorder patients be regarded as autonomous individuals who are responsible for their behavior and thus be candidates for criminal prosecution for committing fraud?

These questions and others have been considered at length by several authors. In general, physicians are responsible for upholding the obligations of the patient-doctor relationship, even though the patient does not. However, these questions have no simple answers; a full discussion of these issues in a staff meeting is often extremely helpful, particularly when the hospital ethicist and attorney can participate in the discussion and treatment planning.

RELATED STORIES:
Factitious Disorders Not Otherwise Specified   Factitious Disorders With Predominantly Psychological Signs and Symptoms   Factitious Disorders With Predominantly Physical Signs and Symptoms   Factitious Disorders and Malingering   Malingering   Factitious Disorders Treatment

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