Faculty Bibliography

Psychiatry consultants are often called on by colleagues to assess a pa-tient"™s capacity to refuse medical care. These situations can expand beyond the boundaries of a decision-making capacity question to become clinically, legally, ethically, and emotionally com-plex situations. This article provides a framework for psychiatrists to navigate these complexities when asked to eval-uate a patient for the capacity to refuse medical care. We review decision-mak-ing capacity as an element of informed consent in order to clarify the psychia-trist"™s role in these consults. We dis-cuss related ethical and legal questions that can arise when a patient refuses treatment. This article also addresses other skills beyond decision-making capacity assessment that psychiatrists may utilize to support nonpsychiatrist colleagues and advance the care of the hospitalized patient.

Olfactory reference syndrome (ORS) describes a constellation of emotional and behavioral symptoms that cause clinically significant distress or impairment arising from the false belief that one is emitting an offensive odor. Despite cases of ORS reported throughout the world over the last century, our knowledge and understanding of ORS remain relatively poor because of the limited literature-mostly case studies and series, but no clinical trials. ORS continues to pose significant diagnostic challenges within our current frameworks of categorizing mental disorders, including the Diagnostic and Statistical Manual of Mental Disorders and International Classification of Diseases. We review the ORS literature and discuss diagnostic parallels and challenges of placing ORS within specific categories. We also review the current research on the neurocircuitry of olfaction and of disorders with potential clinical relevance to patients presenting with ORS. While no primary neuroscientific research has specifically investigated ORS, an overlapping circuitry has been implicated in the neurobiology of obsessive-compulsive, trauma and stressor, and psychotic spectrum disorders, suggesting that the phenomenology of ORS can best be understood through a dimensional, rather than categorical, approach.

This article summarizes the report of the American Medical Association's (AMA) Council on Ethical and Judicial Affairs (CEJA) on ethical practice in telehealth and telemedicine. Through its reports and recommendations, CEJA is responsible for maintaining and updating the AMA Code of Medical Ethics (Code). CEJA reports are developed through an iterative process of deliberation with input from multiple stakeholders; report recommendations, once adopted by the AMA House of Delegates, become ethics policy of the AMA and are issued as Opinions in the Code. To provide enduring guidance for the medical profession as a whole, CEJA strives to articulate expectations for conduct that are as independent of specific technologies or models of practice as possible. The present report, developed at the request of the House of Delegates, provides broad guidance for ethical conduct relating to key issues in telehealth/telemedicine. The report and recommendations were debated at meetings of the House in June and November 2015; recommendations were adopted in June 2016 and published as Opinion E-1.2.12, Ethical Practice in Telemedicine, in November 2016. A summary of the key points of the recommendations can be found in Appendix A (online), and the full text of the opinion can be found in Appendix B (online).

Psychiatrists who provide telepsychiatric services must uphold the standards of ethics and professionalism expected in in-person interactions. Psychiatrists' fundamental ethical responsibilities do not change when they take up a new form of practice. But as in other areas of medicine, the introduction of a new technology - here, Internet use and videoconferencing - raises new ethical challenges, requiring a fresh look at clinical practice and social issues such as equitable access. This review discusses these new challenges under six headings: providing competent, safe care, ensuring informed consent, promoting privacy and confidentiality, managing boundaries, encouraging continuity of care, and addressing health equity. Ethical guidelines for in-person practice have emerged from decades of clinical discussion and carefully observed treatment in the office and hospital setting. New observations, clinical reports, and shared discussion and learning must do the same for telepsychiatry in the years to come.