Forensic Psychiatry, Legal Issues, Death & Palliative Care – Comprehensive Study Notes

PAGE 1 — Origins & Scope of Forensic Psychiatry

• Etymology: “Forensic” ⟶ Latin “forum” → public court arena in Rome.
• Modern connotation: Anything relating to courts of law.
• Forensic psychiatry = subspecialty examining intersections between psychiatry & legal system.

Medical Malpractice: Core Concepts

• Malpractice = civil wrong (tort) arising from physician negligence.
• Negligence = doing what should not be done or failing to do what should be done per current standards.
• Sources establishing standard of care:
  • Expert-witness testimony.
  • Journal articles & professional textbooks (e.g., Kaplan & Sadock).
  • Practice guidelines & ethical codes of professional bodies.

4 Elements (4 Ds)

1. Duty – doctor–patient relationship created obligation of care.
2. Deviation – breach from accepted standard.
3. Damage – patient sustained measurable harm.
4. Direct Causation – deviation linked causally to damage.

• $\text{Liability} \iff \text{all 4 elements present}$

PAGE 2 — Limits, Intentional Torts, Negligent Prescription

• No liability if no doctor–patient relationship (e.g., radio advice with disclaimer).
• Adverse outcome ≠ automatic negligence; psychiatry involves judgment calls.
• Intentional torts (intent or reckless disregard) → assault, battery, false imprisonment, defamation, fraud, invasion of privacy, intentional infliction of emotional distress.
  • Example of fraud: Therapist claims sex is therapeutic.
  • Insurance: Malpractice policies typically exclude intentional tort coverage.

Negligent Prescription Practices

• Common errors:
  • Exceeding recommended dose & failing to titrate.
  • Harmful poly-pharmacy or unreasonable drug combinations.
  • Off-label prescriptions without justification.
  • High pill counts without monitoring; inadequate disclosure of risks.
• Elderly poly-pharmacy = high-risk → mandate meticulous documentation when using multiple psychotropics.

PAGE 3 — Informed Consent in Psychopharmacology & Follow-Up

• Psychiatrist must explain diagnosis, risks, benefits for every med; obtain consent whenever introducing or changing a drug.
• Cognitive impairment → obtain substitute decision-maker’s consent.
• Follow-up frequency: “According to clinical need,” but >6 months gap discouraged.
• Managed-care constraints ≠ defense; duty to treat supersedes payer rules.
• Other negligence arenas:
  • Failure to treat or monitor side-effects.
  • Not checking compliance/diversion.
  • Prescribing addictive meds to vulnerable pts.
  • Stopping drug abruptly.

PAGE 4 — Split Treatment & 5 Components of Informed Consent

• Split treatment = MD provides meds, non-MD does psychotherapy.
• Table 28-1 (Simon): 5 Disclosure Areas

1. Diagnosis
2. Treatment (nature/purpose)
3. Consequences (risks/benefits)
4. Alternatives
5. Prognosis (with & without tx)

• Vignette (43-y female, tricyclic, weekly counseling, suicide) illustrates pitfalls:
  • Minimal MD contact (20 min eval) & no collaboration ⇒ malpractice claim for negligent dx/tx.

PAGE 5 — Ethical Mandate & Liability in Split Treatment

• APA Ethics §V-3: Supervising psychiatrist must spend “sufficient time” to assure proper care.
• Merely serving as “medication technician” = substandard.
• Psych MD retains full responsibility; therapist’s liability does not replace it.
• Requirements:
  • Remain informed of pt’s status & non-MD therapy quality.
  • Clear delineation of each discipline’s responsibilities to pt.
  • Joint periodic re-evaluation; coordinated termination.
• Lawsuits usually pull in both psychiatrist & therapist.
• Hospitalization capacity: MD must have admitting privileges or pre-arranged backup.

PAGE 6 — Privilege vs. Confidentiality (Foundations)

• Privilege = legal right (patient-owned) to resist forced disclosure despite subpoena.
  • Exceptions: Military courts; certain jurisdictions.
  • Jaffee v. Redmond (1996) ⇒ SCOTUS recognizes psychotherapist–patient privilege under FRE 501.
• Confidentiality = ethical duty to keep patient info secret.
  • “Circle of confidentiality” includes treating staff, supervisors, consultants.
• Subpoena duces tecum → produce records plus attend.
• Emergencies: limited disclosure allowed; still obtain consent when possible & debrief later.
• Each info release requires separate, documented permission; permission ≠ obligation if clinically harmful.

PAGE 7 — Insurance, Supervision, Social Media, Mandated Reporting

• Third-party payers & QA necessitate some disclosure → confidentiality not absolute.
• Trainees must discuss cases with supervisors → sanctioned breach.
• Institutionalized court-ordered pts → treatment plans reviewed by boards.
• Internet/social-media comms risky → not confidential; subpoena-able; risk of patient identification.
• Child-abuse reporting: universal legal duty; confidentiality overridden by statute.

PAGE 8 — High-Risk Clinical Situations (Tardive Dyskinesia, Suicide)

• Tardive Dyskinesia (TD)
  • Incidence: $10!–!20\%$ (could reach $50\%$) after >1 yr on 1st-gen antipsychotics; higher in elderly.
  • Negligence claims when failure to obtain informed consent, monitor, diagnose, or act on TD.
• Suicide Liability
  • Inpatient suicides scrutinized: assumption of greater clinician control → foreseeability & preventability judged.
  • Absence of “professional standard” for prediction; but standards exist for risk assessment & precautions (e.g., safety plan, observation level, hospitalization decisions).

PAGE 9 — Violence & Tarasoff Doctrine

• Duty to protect identifiable 3rd parties when imminent threat.
• Tarasoff I (1976) – duty to warn potential victim/police.
• Tarasoff II (1982) – duty broadened to protect (hospitalize, med-adjust, warn, etc.).
• Options: voluntary/invol hospitalization, warning, medication change, increased sessions.
• Consider Tarasoff as national standard, even w/o state statute.

PAGE 10 — Tarasoff Facts & Implications

• Case details: Poddar’s threat → therapist notified campus police; supervisor destroyed records; Tatiana Tarasoff killed 2 months later.
• Court: therapist must take “reasonable steps” – warn victim, notify police, or other measures.
• Debate: hindrance to confidentiality vs. public safety; clinicians fear defensive practices.

PAGE 11 — Hospitalization Law & Parens Patriae

• States provide invol hospitalization when pt = danger to self/others or cannot care for self.
• Parens patriae (“father of country”) → state acts as surrogate parent.
• Commitment term replaced by “hospitalization.”

Four Admission Routes (ABA endorsed)

1. Informal – voluntary, free to leave AMA.
2. Voluntary – written request; free to leave AMA.
3. Temporary/Emergency – 1 MD cert; confirm by staff; limited days (≈15).
4. Involuntary – 2 MDs + court oversight; duration e.g., 60 days, periodic review; habeas corpus.

PAGE 12 — Patients’ Rights: Treatment & Refusal

• Right to Treatment (Rouse v. Cameron 1966; Wyatt v. Stickney 1971): invol pt must receive individualized, adequate treatment or be discharged.
• Wyatt standards: staffing ratios, facility standards, individualized plans; rights to privacy, least restrictive environment, refuse psychosurgery/ECT without consent.
• Right to Refuse Treatment
  • Emergency exception.
  • Key cases: O’Connor v. Donaldson 1976 (cannot confine harmless mentally ill), Rennie v. Klein 1979 (appeal process), Rogers v. Oken 1981 (guardian may consent).

PAGE 13 — Civil Rights: Least Restrictive, Visitation, Communication

• Least Restrictive Alternative → outpatient vs. inpatient; open vs. locked ward; medication vs. seclusion/restraint.
• Visitation Rights: reasonable hours; clergy/attorney/private MD unrestricted barring emergencies.
• Communication: private calls/mail; supply stationery; exceptions for threats/harassment.
• Privacy & Economics: right to private facilities, clothing, money; paid for hospital work (anti-peonage).

PAGE 14 — Seclusion & Restraint

• Indications (Table 28-2): imminent harm, treatment adjunct, sensory reduction, patient request.
• Contraindications: unstable medical, delirium unable to tolerate, overt suicidality needing 1:1, drug overdose requiring close monitoring, punishment/convenience.
• Restrictions (Table 28-3): written time-limited order, regular review, re-authorize extensions.

PAGE 15 — Informed Consent & Minors

• Negligence claims now routinely paired with informed-consent claims (no expert required).
• Even successful outcome irrelevant if consent missing.
• Minors: parent/guardian consent; states allow self-consent for $\text{STI}$, pregnancy, substance use, contagious diseases.
• Emergencies → treat without parental consent.
• Mature minor rule & emancipated minors.
• Gault 1967: juveniles entitled to counsel, notice, confrontation.

PAGE 16 — Consent Form Essentials & Child Custody Principles

• Consent form must include: explanation, experimental nature, risks/benefits, alternatives, Q&A, right to withdraw.
• Child custody: “best interests of the child.” Tender-years doctrine favors mothers but eroding.
• Courts intervene (care & protection) when neglect/abuse; fathers winning ~5 % custody.

PAGE 17 — Testamentary & Contractual Competence

• Testamentary capacity: know property, making bequest, natural heirs.
• Reconstruction via records & experts; videotaping signing; ante-mortem forensic eval recommended.
• Incompetence → guardian; competence task-specific; only judge’s ruling decisive.
• Durable Power of Attorney permits advance designation of surrogate.

PAGE 18 — Criminal Law: Competence & Execution

• Dusky standard: rational & factual understanding + ability to consult lawyer.
• Competence to be executed (Ford v. Wainwright): awareness needed to satisfy retribution, religious preparation, possible exoneration.
• AMA & APA oppose clinician participation in executions.

PAGE 19 — Insanity Tests: M’Naghten, Impulse, Durham, ALI, GBMI

• Crime requires actus reus + mens rea.
• M’Naghten (1843): right–wrong test; unaware of nature/quality OR unaware act was wrong.
• Irresistible Impulse: inability to resist even with “policeman at elbow.”
• Durham/Product Rule (1954): act product of mental disease; abandoned (Brawner 1972).
• ALI/Model Penal Code (1962): lacks substantial capacity to appreciate criminality or conform conduct.
• Sociopathy excluded.
• GBMI verdict: same sentencing as guilty; treatment provided within prison system.

PAGE 20 — Other Forensic Domains

• Emotional damage litigation (PTSD, camp survivors) → psych eval crucial.
• Recovered memories: lawsuits vs. parents & therapists; risk-management principles (Table 28-4) stress neutrality, documentation, consultation.
• Worker’s compensation for psych injuries; forensic evals common.
• Sexual exploitation → civil, criminal, licensure, ethical sanctions (Table 28-5).

PAGE 21 — HIPAA & Privacy Rule

• HIPAA 1996; Privacy Rule enforced by HHS OCR.
• Patients’ rights (Table 28-6): notice of privacy practices, record access/amendment, disclosure accounting, authorization for non-routine uses, alternate communication means, complaint process.

PAGE 22 — Key References (Selected)

• Adshead G (2005) Factitious disorder expert testimony.
• Andreasson H et al. (2014) Length of forensic stay predictors.
• Simon RI, Shuman DW, Gold LH – forensic textbooks.

PAGE 23 — Death & Dying: Definitions

• Death = irreversible cessation of vital functions.
• Dying = process of losing functions; part of development.
• Good death: minimal avoidable suffering, aligns w/ values & ethics.
• Bad death: needless suffering, violated wishes, indecency.
• Uniform Determination of Death Act (1981): irreversible cessation circulatory/respiratory or whole-brain (incl. brainstem) functions.
• Pediatric brain-death: two exams separated by $48,24,12$ hrs depending on age.

PAGE 24 — Legalities & Kübler-Ross Stages (1-2)

• MD signs death certificate → cause & manner (natural, accident, suicide, homicide, undetermined).
• Coroner autopsy if unattended.
• Psychological autopsy reconstructs mental state (e.g., suicide vs. homicide).
• Kübler-Ross 5 stages: 1 Shock/Denial, 2 Anger.
  • Clinical pearls: denial may be adaptive if tx pursued; anger often displaced onto staff.

PAGE 25 — Kübler-Ross Stages (3-5) & Near-Death Experiences

• Stage 3 Bargaining – negotiate with deity/MD; reassure equal care regardless.
• Stage 4 Depression – can be normal sadness or MDD needing meds/ECT.
• Stage 5 Acceptance – emotional resolution; can foster dignity & hope.
• Near-death experiences: out-of-body, tunnel, peace; may lead to life-style changes.

PAGE 26 — Developmental Perspectives on Death

• Children’s causes of death = accidents/homicide/suicide → trauma for survivors.
• Preschoolers: view death as temporary; fear separation; need reassurance.
• School-age: understand finality but think affects older ppl.
• Adolescents: formal operations; fear loss of control, body image; need inclusion in decisions.
• Adults: top fears include separation, burden, losing control, pain.
• Elderly: often reconciled; Erikson’s Integrity vs. Despair influences acceptance.

PAGE 27 — Bereavement Terminology & Normal Grief

• Grief = subjective response; mourning = societal expression; bereavement = state.
• Course: protest → searching → despair/detachment → reorganization.
• Loneliness = most persistent spousal-loss symptom.
• Bittersweet memories triggered contextually even lifelong.

PAGE 28 — Anticipatory & Anniversary Grief; Mourning Rituals

• Anticipatory grief may ease or intensify later bereavement.
• Anniversary reactions on death date/holidays.
• Funerals, wakes, Shiva, etc. legitimize loss, support community, counter denial.

PAGE 29 — Bereavement vs. Major Depression (Table 29-2) & DSM Approach

• Bereavement usually lacks morbid guilt, worthlessness, psychomotor retardation.
• Dysphoria stimulus-bound; duration <$2$ mo vs. chronic in MDD.
• DSM-5 removed bereavement exclusion; proposed “Persistent Complex Bereavement Disorder.”
• ICD-10 → Adjustment Disorder, Grief Reaction (Table 29-3).

PAGE 30 — Complicated Grief Types & Medical/Psych Risks

• Chronic – prolonged bitterness, idealization.
• Hypertrophic – intense, after sudden death, potential family disruption.
• Delayed – absent early grief, prolonged denial.
• Traumatic grief – chronic + hypertrophic; intense yearning + intrusive death images.
• Medical risks: ↑ mortality (CV disease, suicide), ↑ substance use.

PAGE 31 — Biologic & Phenomenologic Aspects; Grief Phases (Table 29-4)

• Acute grief → disrupted rhythms, immunosuppression, lymphocyte/NK cell function ↓.
• Widow(er) mortality highest immediate months; men risk > women.
• 3 overlapping phases: Shock/Denial, Acute Anguish, Resolution.

PAGE 32 — Child & Adolescent Bereavement; Adult/Elderly Loss

• Children manifest grief via behavior (anger, play) more than verbal sadness; grief re-emerges at developmental milestones.
• Adolescents: potential delinquency, sexual acting-out; require candid communication.
• Adult losses: spouse vs. child; stillbirth & SIDS produce guilt; AIDS-related loss entwines stigma.
• Elderly face multiple losses; loneliness prominent.

PAGE 33 — Grief Therapy & Clinical Management

• Normal grief seldom needs psychiatry; watch for suicidality, MDD → treat.
• Sleeping meds only short-term; avoid numbing essential grief work.
• Grief therapy: encourage expression, legitimize ambivalence; groups & self-help effective.
• 30 % widows/widowers socially isolate → group support combats loneliness.

PAGE 34 — Psych Symptoms in Palliative Care & Prevalence

• Anxiety, depression, delirium most common; often overlap (“negative affect”).
• Prevalence: severe depression $15\%$, depressive sx $30\%$; delirium up to $85\%$ in late stage.
• Psychiatric dx linked to longer hospital stays (≈$60$ additional days).

PAGE 35 — General Treatment Principles & Anxiety Management

• Treat sx rapidly even as etiologic work-up ongoing.
• Anxiety somatic presentation: restlessness, SOB, tachycardia; increases pain.
• Use relaxation, benzodiazepines (e.g., clonazepam), reassurance.

PAGE 36 — Depression Identification & Endicott Criteria (Table 29-5)

• Endicott substitution swaps somatic criteria for psychological equivalents to adjust for terminal illness.
• Antidepressants effective even near death; psychostimulants (methylphenidate) for alertness.

PAGE 37 — Delirium in Terminal Phase

• Mild confusion may mimic depression/anxiety; delirium prevalence near death ≈$75!–!85\%$.
• Hypoactive delirium under-recognized; low-dose antipsychotics (olanzapine, haloperidol) helpful without tapering opioids.

PAGE 38 — Family Dynamics & End-of-Life Decision-Making

• “Conspiracy of silence” hinders meaningful closure.
• Family-centered sessions reopen dialogue, resolve conflicts, allocate caregiving roles.
• Transition to palliative care requires acknowledgement of nearing death.

PAGE 39 — Advance Directives & Settings of Death

• Advance care planning: living will, health-care proxy, DNR/DNI.
• Infographic checklist: early discussion, document creation, copy distribution.
• Sites of death: acute hospital (majority), nursing home, inpatient hospice, home hospice.
• Home hospice → 24-h phone, supplies, staff visits; enhances control & competence.

PAGE 40 — Physician Attitudes, Communication, & Breaking Bad News

• Some MDs fearful of death; risk factors (Table 29-6) include over-identification, unresolved grief, insecurity.
• Patient’s Bill of Rights (1972) demands honest disclosure.
• Bad-news protocol: private setting, clear language, allow questions, avoid precise prognostic timelines.

PAGE 41 — Terminal Care Decisions: Brain Death & PVS

• Brain death: loss of cortical + brainstem fxn; legal death.
• Persistent Vegetative State (PVS): sleep–wake cycles + autonomic fxn but no awareness; ethical to withdraw life-support.
• Quinlan case ⇒ hospital ethics committees & living-will legislation.

PAGE 42 — Family Caregiver Tasks & Stress (Table 29-9)

• Tasks: med administration, ADLs, symptom mgmt, equipment, emotional/spiritual support, finances.
• 25-30 % caregivers lose job; more than half cut hours.

PAGE 43 — Palliative Care & Pain Management Basics

• Palliative care = relief of suffering; includes environment changes, discontinuing burdensome monitoring.
• Pain types (Table 29-10): somatic, visceral, neuropathic, psychogenic.

PAGE 44 — Opioid Principles & Adjuvant Analgesics

• Aggressive, scheduled dosing superior to PRN.
• Switching opioids: account for incomplete cross-tolerance; hydromorphone when morphine meta build-up.
• Table 29-11 lists common opioids & equipotent doses.
• Adjuvants: antidepressants, gabapentin, phenothiazines, steroids, amphetamines.

PAGE 45 — Managing Other Symptoms (Table 29-12)

• Cachexia, delirium, dysphagia, dyspnea, fatigue, incontinence, nausea, skin breakdown = common.
• THC/dronabinol for chemo nausea; morphine bolus for dyspnea.

PAGE 46 — Hospice Care Evolution

• St. Christopher’s (1967); Connecticut Hospice (1974).
• Medicare hospice benefit (1983) → certification of ≤$6$ mo prognosis & palliative focus.
• Models: inpatient units, home care, nursing home hospice.
• Outcomes: high family satisfaction; cost-effective.

PAGE 47 — Neonatal & Pediatric End-of-Life Ethics

• Preemie & multiple births ↑ life-support dilemmas.
• AAP permits non-treatment when irreversible coma or futile.
• Children need developmentally tailored disclosure; fear separation; include parents in care tasks.

PAGE 48 — Spiritual & Alternative Medicine Considerations

• Religion may bolster coping; chaplains integral part of team.
• Alternative/complementary therapies (detox diets, megavitamins, metabolic therapy) lack evidence but may enhance sense of control.

PAGE 49 — Euthanasia & Physician-Assisted Suicide (PAS)

• Definitions: Voluntary vs. involuntary; active vs. passive.
• Arguments pro: autonomy & dignity; Arguments con: sanctity of life, treatable depression, slippery slope.
• AMA, APA, WMA oppose active euthanasia & PAS; support aggressive palliation even if life-shortening.

PAGE 50 — Legal Landscape & Oregon Data (Table 29-13)

• SCOTUS (1997) ruled no constitutional right to PAS; left to states.
• Oregon Death-with-Dignity Act (1994) criteria: adult resident, <$6$ mo prognosis, 2 oral + 1 written request, 2 MD confirmations, 15-day wait, etc.
• Early 4-yr stats: 8/10,000 deaths; 85 % loss-of-autonomy cited; 80 % hospice-enrolled.
• Other states: Washington 2008, Montana 2009, Vermont 2011.

PAGE 51 — AMA 8-Step Protocol for Requests (Table 29-14)

1. Rule-out psych illness.
2. Assess decision capacity.
3. Explore goals.
4. Address physical/psych/social/spiritual suffering.
5. Discuss full care spectrum.
6. Seek colleague consultation.
7. Ensure optimum palliative care in place.
8. Explain incompatibility of PAS with medical ethics.

PAGE 52 — Future Directions

• Enhance education on death/dying in med curriculum.
• Universal access to pain control, hospice, home care → may reduce PAS demand.
• Guard against economic, racial, age biases in terminal care.
• Ongoing legal & ethical evolution as technology advances.