Adjustment Disorder and Internet Gaming Disorder

(Photo by Fredrick Tendong on Unsplash)

The final project for my Online Digital Obsessions class asked us to create a fictitious patient with an electronic addiction, adopt the role of a college counselor, do a full psychosocial assessment, and create a treatment plan for this patient’s therapeutic intervention. In the end, we were required to predict the challenges and outcomes for this patient. At this time, there is no official diagnosis, “Internet Gaming Disorder.” The proposed diagnosis was referred for further study by the American Psychiatric Association. However, it is expected to be adopted in the future. Playing video games is only a problem when it becomes the dominant interest in somebody’s life and undermines their normal functioning in day-to-day living.

Adjustment Disorder and Internet Gaming Disorder

by Dawn Pisturino

Thomas Edison State University

Introduction

       Jeremy Reed is an 18-year-old Caucasian male who was referred to counseling by his academic advisor for depression.  He says that adjusting to university life has been difficult, and he has been feeling increasingly depressed.  He began playing World of Warcraft on his computer to relieve stress and cope with his depressed feelings.  He became so involved in the game that he began neglecting his homework, and his grades are suffering.  His academic advisor referred him to counseling so he does not lose his full-ride scholarship to the university. 

       The client says that playing World of Warcraft makes him “feel good,” and he does not want to stop.  He has made new friends and become a “top player.”  He admits to feeling more depressed and irritable when he is not playing the game.  I explain to Jeremy—who is a biology major—that he feels good when he plays World of Warcraft because the activity activates the reward system in his brain and stimulates the release of dopamine.  The more he activates this system, however, the more he craves the gratifying pleasure produced by the game.  He needs to spend more hours playing the game to reach that same level of pleasure and craves playing the game when he is not able to do so.  Playing the game has become more important to him than his academic performance, so he is neglecting his schoolwork and falling behind.  As he loses control over his impulse to play, I explain, his life will spiral more and more out of control.  He is at great risk for not sleeping and eating, neglecting his hygiene, alienating his roommate, and losing his scholarship and admission to the university if he does not reduce his game playing and start improving his academic performance.  Jeremy agrees that this is true but also states that he does not want to completely give up playing the game (Gros et al., 2020, pp. 2-4; Tavormina & Tavormina, 2017, pp. 422-424).

Clinical Assessment

       For this assessment, I am using the Therapist Clinical Assessment/Psychosocial Assessment tools used routinely at Flagstaff Medical Center Behavioral Health Unit in Flagstaff, Arizona, and the PHQ-9 questionnaire because I am familiar with these forms.  The PHQ-9 is used to screen clients for symptoms of depression and has a proven track record of accuracy and reliability.  Clients who fill out the form are scored based on their responses.  Scores equal to or greater than 10 can indicate a depressive disorder (American Psychological Association, 2020, para. 1-2).

       The client, Jeremy Reed, presents as withdrawn with a flat affect and a disheveled appearance.  His thought processes are linear and logical with organized thinking.  He is alert and oriented.  His speech is coherent and clear, but he is delayed in his responses.  His psychomotor activity appears normal, but he makes poor eye contact.  His thought content is realistic, but he exhibits poor insight into his excessive video game activity even though his memory and judgment are within normal limits.  He denies hearing voices, having hallucinations, or experiencing extreme mood swings.

       Jeremy denies any current suicidal and homicidal ideation.  He denies any actual self-harm or harm to others.  He denies any thoughts of suicide/homicide in the past or making any gestures or threats of violence against others.

       The client denies any history of sexual, verbal, emotional, or physical abuse.  He does not recall witnessing any extreme acts of violence.  He reports that his parents argue sometimes but always resolve their differences amicably.  He is an only child and has no half-siblings or step-siblings.

       Jeremy confirms that he is a healthy heterosexual male with little sexual experience.  He is currently single and not sexually active.  Although he would like to have a girlfriend, he believes it would interfere even more with his studies.

       The client says he is a nominal Protestant and only attends church at Christmas and Easter.  He has experimented with yoga and meditation in the past to live a healthier lifestyle.  He does not routinely pray or engage in spiritual practices.

       Jeremy currently lives on campus in a dorm and has no housing needs.  He is unemployed at the moment but worked part-time at Burger King in high school.  He is studying biology and plans a career as a biologist.  Since he has a full-ride scholarship to the university, his parents help out with his expenses.  He says he does not want to lose his scholarship or disappoint his parents.

       The client has no military experience and no legal difficulties.  He has never been arrested or suspended from school. As far as he knows, his developmental history was normal.

       Jeremy says he played basketball in high school and still enjoys playing when he can find the time and other players.  He has no significant medical history, no known allergies, and takes no prescribed medications. The client appears well-nourished and physically fit.  His tonsils were removed at age 10.  He broke his arm when he fell off his bike at age 12.  He is already registered with the university’s student health services.  Currently, he reports staying up late playing video games, feeling tired the next day, and eating too much junk food.  He says he lacks the motivation and concentration to study.

       The client denies any mental health history.  He states that his depression and anxiety began a couple of months ago when he began his freshman year of college.  This is his first time living away from home, and he is having trouble adjusting to university life, living with a roommate, and being away from his family.  He is carrying a full load of credits and feels stressed out and overwhelmed by all the homework, expectations, and pressure.

       Jeremy believes his paternal grandfather was a heavy smoker and alcohol drinker.  His father drinks alcohol occasionally, mostly on holidays.  His mother takes Vistaril occasionally for anxiety.  He admits to trying cannabis twice but did not like it.  He denies all other substance use except alcohol, which he uses occasionally on the weekends.  His only source of caffeine is Coca-Cola.

       The client states that his main form of recreation right now is playing Internet video games, i.e., World of Warcraft.  He wants to cut back and resume his studying, but he derives a lot of satisfaction from the game and does not want to stop playing the game completely.  He admits that he loses track of time while on the game.  He is not fully motivated to quit.

       Jeremy describes his strengths as being goal-oriented and a good student.  He is strongly motivated to complete his college degree and start work as a biologist.  He describes his weaknesses as being too introverted and serious.  He believes he has poor coping skills when it comes to stress.  He wants help overcoming his depression and anxiety but says he is not interested in taking medication.  Although he does not see playing video games as a serious problem, he admits that it has already affected his grades and academic standing.  His PHQ-9 score is 13, with 4 boxes checked in the gray areas.  His score indicates moderate depression that is making it difficult for him to function at his normal baseline (American Psychological Association, 2020, para. 1-3).

Probable Diagnoses and Treatment Plan

Probable Diagnoses

Problem #1 – Adjustment Disorder with Mixed Anxiety and Depressed Mood (ICD Code   F43.23) ( ICD-10 Coded, 2022, para. 1)          

       Adjustment disorder occurs when a person is faced with a stressful life situation, such as going away to school.  Jeremy describes having a difficult time adjusting to university life and being away from home.  He has no prior history of depression, anxiety, or other mental health issues.  His symptoms appeared less than three months ago after arriving on campus for his freshman year, meeting the DSM-V criteria.  He reports increasing depression and anxiety that are affecting his ability to cope with his new situation.  If Jeremy agrees with the assessment and treatment plan, his prognosis looks good. (American Psychiatric Association, 2015, pp. 120-121; Kenardy, 2014, para. 1-3; Mayo Clinic, 2023, para. 1-13).

Problem #2 – Internet Gaming Disorder (no ICD code until ICD-11) ( Petry et al., 2015, pp. 1,7)

       Internet gaming disorder (IGD) appears in the Diagnostic and Statistical Manual of Mental Disorders, 5^th Edition (DSM-V) in Section III under the heading of “Conditions for Further Study.”  The DSM-V provides criteria for IGD that closely align with the criteria for other addictive disorders, like substance use disorder and gambling disorder.  Clients who meet at least five of the criteria could be considered suffering from or at high risk for Internet gaming disorder (Petry et al., 2015, pp. 1-5).

       Jeremy has been playing Internet video games to relieve stress, anxiety, and depression.  He has been spending increasing amounts of time playing video games and spending less time sleeping and studying.  As a result, his academic performance has declined, and he risks losing his full-ride scholarship.  Currently, Jeremy meets six of the criteria on the DSM-V list of criteria: preoccupation, tolerance, neglecting other activities, escapism, and risking losing his educational opportunities.  He has only been playing for a couple of months and is not fully motivated to quit, even though he recognizes that he needs to make some changes in his life.  If he agrees with the assessment and treatment plan, however, his prognosis looks good (Petry et al., 2015, pp. 2-3).                                           

Treatment Plan

Goals and Objective

       Jeremy’s primary concern is protecting his full-ride scholarship and earning his biology degree.  His second goal is to learn new coping skills to deal with his depression, anxiety, and stress.  His third goal is to achieve more balance in his life between studying and recreation.  His fourth goal is to reduce his time playing video games and participate in more physical activities, like basketball.  Overall, the client’s objective is to return to his normal baseline status before going away to college.  He wants the same self-confidence and control over his life that he had before.  He wants to regain his motivation and commitment to studying and succeeding in school.  He wants a positive outcome that will help him grow as a person and mature into adulthood.

Action Plan

       Psychotherapy is the primary evidence-based treatment for both adjustment disorder and Internet gaming disorder (IGD).  The client will benefit from weekly psychotherapy sessions to discuss how and why leaving home and starting college has made such a huge impact on his well-being, including his use of video games to relieve stress.  If psychotherapy is insufficient to stabilize the client, a course of medication may be helpful.  The client, however, is unwilling to try medication at this time (American Psychiatric Association, 2015, pp. 63, 121; Gros et al., 2020, p. 15; Kenardy, 2014, para. 4, 6-7, 10; Mayo Clinic, 2023, para. 22-23; Petry et al., 2015, p. 6; Tavormina & Tavormina, 2017, p. 424; Torres-Rodriguez et al., 2017, pp. 1003, 1005-1006, 1010-1011).

Interventions

       Cognitive behavioral therapy (CBT) is effective in helping clients to recognize and re-frame harmful patterns of thought and behavior.  The client will be referred to a therapist who is proficient in CBT since it has been proven successful in treating both adjustment disorder and IGD.  I will encourage the client to continue seeing me on a weekly basis at the clinic for one-to-one motivational and support counseling and provide him with opportunities to participate in clinical workshops that will help him to learn new skills in stress management, anger management, relaxation activities, mindfulness and resilience training, and goal-focused solutions.  With Jeremy’s cooperation, we will devise a schedule that maps out times for study, recreation, and playing video games that supports his class schedule and enhances his goals and objective.  I will suggest that he join a campus support group for new students.  I will refer him to mental health peer support services for monitoring and help.  If the client requires medication, I will refer him to a psychiatrist or psychiatric nurse practitioner for evaluation and prescriptions. 

I will get consent from the client to speak to his parents, make them aware of the situation, and offer them support.  Since Jeremy is in a vulnerable age group, he needs intense support to get through this temporary setback.  Otherwise, this could turn into an ongoing issue (American Psychiatric Association, 2015, pp. 63, 121; Gros et al., 2020, p. 15; Kenardy, 2014, para. 4, 6-7, 10; Mayo Clinic, 2023, para. 22-23; Petry et al., 2015, p. 6; Tavormina & Tavormina, 2017, p. 424; Torres-Rodriguez et al., 2017, pp. 1003, 1005-1006, 1010-1011).

Challenges

       Since Jeremy is highly motivated to protect his full-ride scholarship and complete his degree, his prognosis is good as long as he follows the treatment plan.  Challenges include ongoing depression, anxiety, and stress that may undermine his motivation, time constraints due to carrying a full load, and relapsing on playing video games.  I will provide him with literature and books that will help him to understand the biological, neurological, and psychological nature of his problems.  This may pique his interest as a biology student and keep him involved in his therapy.  I will suggest that he drop any extra credits that he is taking.  The client will be given positive encouragement and reinforcement to stick to his goals.  I will work with his assigned  peer support person to monitor his progress and participation.

Conclusion

       Eighteen-year-old Jeremy Reed was referred to my office for depression, anxiety, and excessive playing of video games by his academic advisor.  Jeremy’s symptoms began when he moved into the campus dorm to start his freshman year of college a few months ago.  Since then, he has been spending more time playing video games and less time studying.  His academic performance has suffered, putting his full-ride scholarship at risk.

       This client is positive for symptoms of adjustment disorder and Internet gaming disorder.  His age makes him a high risk for long-term mental health issues, including suicide, if he does not participate in treatment.  If he cannot control, reduce, or eliminate his video game activity, he will continue to decline academically, which will impact other areas of his life (Kenardy, 2014, para. 2).

References

American Psychiatric Association. (2015). Understanding mental disorders: Your guide to

       dsm-5. Washington: American Psychiatric Publishing.

American Psychological Association. (2020). Patient health questionnaire. American

       psychological association. Retrieved from

       http://www.apa.org/pi/about/publications/caregivers/practice-settings/assessment/tools/

       patient-health.

Gros, L., Debue, N., Lete, J., van de Leemput, C. (2020). Video game addiction and emotional

       states: Possible confusion between pleasure and happiness. Frontiers in psychology.

       doi: 10.3389/fpsyg.2019.02894.

ICD-10 Coded. (2022). ICD-10-cm code f43.23. ICD-10 coded. Retrieved from

       http://www.icd10coded.com/cm/F43.23/

Kenardy, J. (2014). Treatment guidance for common mental health disorders: Adjustment

       disorder. Australian psychological society inpsych 2014, 36(5). Retrieved from

       http://www.psychology.org.au/inpsych/2014/october/kenardy.

Mayo Staff Writers. (2023). Adjustment disorders. Mayo clinic. Retrieved from

       http://www.mayoclinic.org/diseases-conditions/adjustment-disorders/diagnosis-treatment/

       drc-20355230.

Petry, N.M., Rehbein, F., Ko, C., O’Brien, C.P. (2015). Internet gaming disorder in the dsm-5.

       Current psychiatry reports, 17(72). doi: 10.1007/s11920-015-0610-0.

Tavormina, M.G.M., Tavormina, R. (2017). Playing with video games: Going to a new

       addiction. Psychiatria danubina, 29(3), 422-426.

Torres-Rodriguez, A., Griffiths, M.D., Carbonell, X. (2017). The treatment of internet gaming

       disorder: A brief overview of the pipatic program. International journal of mental health

       addiction. doi: 10.1007/s11469-017-9825-0.  

~

Dawn Pisturino, RN

February 19, 2023; March 24, 2023

Copyright 2023 Dawn Pisturino. All Rights Reserved.

The Healing Power of Music

(Photo by Dark Rider on Unsplash)

The Healing Power of Music

by Dawn Pisturino

Both Aristotle and Plato commented on the healing power of music. But it was not until the 20th century that the idea of music therapy began to take hold.

Music therapists are trained healthcare professionals who utilize music to encourage wellness, healing, and a better quality of life. They work in psychiatric facilities, hospitals, nursing homes, hospice programs, schools, and other organizations.

People with mental illness benefit from the influence that music has over mood and emotions. In the hospital setting, music has been used to reduce pain and suffering, relieve tension, and promote sleep.  Nursing homes employ music therapists to keep senior citizens active and socially involved. Music has been used in hospice programs to provide comfort, relaxation, and a better quality of life for people who are terminally ill. Music therapy is used in special learning programs at schools to improve communication and coordination skills.

Research has shown that music can improve depression and insomnia, reduce blood pressure, lower respiration and heart rates, and alleviate nausea caused by chemotherapy.

Children who take music lessons tend to have higher IQ scores and do better in school. In the home, music is a valuable tool for reducing stress, engaging in physical exercise, and creating a more positive environment. Employers have found that background music in the workplace can help reduce stress among employees.

Listening to the sounds of nature can also be therapeutic. Birds singing, waves crashing on the beach, a babbling brook, the wind blowing playfully through wind chimes, whale songs, the purring of a cat — these all have the power to soothe frazzled nerves and fill us with a sense of comfort and joy.

Dawn Pisturino

April 2, 2007; March 13, 2023

Copyright 2007-2023 Dawn Pisturino. All Rights Reserved.

Published in The Kingman Daily Miner, April 24, 2007.

[Please note that I will not be posting again until Friday]





Electronic Addictions, Las Vegas Style

(Photo by Nathana Rebouças on Unsplash)

When people go into a casino, they are mesmerized by the colors, bright lights, and dinging bells of slot machines that, nowadays, look suspiciously like video games. In fact, the video game craze has influenced what kinds of games casinos offer to their customers. The live-action table games are slowly being replaced with interactive video games. Not only is this cost-effective for casinos, but machines can be manipulated to take more of the customer’s money.

But why are people so attracted to the Las Vegas type of bells and whistles that they find in casinos, amusement parks, and video arcades? Why are they mesmerized by these same effects on their video games, computers, and smartphones? Are consumers being trained to use electronic devices like toys – and not just tools for business and communication?

According to an article posted on the Psychology Today website, “the typical American spends about 1460 hours per year on their smartphone” (Brooks, 2019, para. 2). The author attributes this behavior to the variable ratio reinforcement schedule, a conditioning process that draws users over and over again to their electronic devices, and in particular, video games. With the right psychological rewards in place, users can quickly become hooked (Brooks, 2019, para. 3).

In a variable ratio reinforcement schedule, rewards are delivered randomly so that the electronic device user has to use the device more and more in order to get the psychological reward. If the user stops using the device, he gets no reward. But if he keeps going, the reward will eventually be delivered, hooking the user even more (Brooks, 2019, para. 4-5).

Why does this happen? Dopamine is released by the brain when the reward system is activated. A random reward reinforces the reward system further, leading the electronic device user to unconsciously look for the stimulus that delivers the reward (Brooks, 2019, para. 7).

The anticipation and expectation of reward entice the device user to keep using the device and receiving the reward once more . . . over and over again . . . until the user has lost control over his own impulses. Unless the user has strong sales resistance and self-discipline, he may find himself glued to his device, drawn there like a bee to honey. This is why the mental health diagnosis of impulse control has become so pertinent to the abuse and overuse of electronic devices (Brooks, 2019, para. 8).

Reference

Brooks, M. (2019). The “vegas effect” of our screens. Psychology Today. Retrieved from

       http://www.psychologytoday.com/us/blog/tech-happy-life/201901/the-vegas-effect-our-screens.

Dawn Pisturino

Thomas Edison State University

January 7, 2023; January 23, 2023

Copyright 2023 Dawn Pisturino. All Rights Reserved.

Reprise: Lessons from Lewis Carroll

Have you ever felt like Alice falling down the rabbit hole? It wasn’t until she hit rock bottom that she found the tools to cope with her environment.

Or what about the White Rabbit? His obsession with time makes him sound like a classic Type A personality.

We all know people who act as if they are running a marathon race against Time. The most familiar thing out of their mouths is, “I’m busy. I don’t have time. Not right now. Good grief, I have to be somewhere in five minutes!”

Like the Red Queen, they are always running in place and getting nowhere fast. And no matter how hard they try to catch up, they never will. And no matter how much we try to convince them to slow down, they never will—until they suffer a heart attack or some other misfortune.

Appearing and disappearing like the Cheshire cat, they smile smugly and proudly tell us how terribly important they are; but they may as well be saying, “We’re all mad here. I’m mad. You’re mad.”

“How do you know I’m mad?” said Alice.

“You must be,” said the Cat,” or you wouldn’t have come here.”

Alice had many curious adventures in Wonderland, but even she had her limits. When she finally got tired of the Queen of Hearts screaming, “Off with their heads!” and all the other zany, madcap characters, she stood up and cried, “I can’t stand this any longer!”

And with one pull of the tablecloth, she was back home again with her beloved kitten Dinah.

The wacky world of Lewis Carroll can be seen as a reflection of our own crazy world. And, just like Alice, we sometimes have to pull ourselves in many directions to adapt to our environment. But when we can no longer tolerate living in this way, it’s time to stand up and shout, “Enough is enough!”

(White Rabbit – Jefferson Airplane)

Dawn Pisturino

2007; January 18, 2023

Published in The Kingman Daily Miner, September 11, 2007.

Copyright 2007-2023 Dawn Pisturino. All Rights Reserved.





Ayurvedic Land and Seed Theory: Cleansing to Restore Balance

An important concept in Ayurveda (traditional East Indian medicine) is the land and seed theory.

It’s really very simple. The body is the “land.” The “seed” is a virus, bacteria, toxic substance — anything that can take root and cause disease. 

In order to function properly, the body needs to maintain balance through good digestion and regular elimination. When toxins build up in the system through poor diet, inadequate digestion, or slow elimination, the “land” becomes fertile for the “seed” to grow and thrive, thereby causing discomfort and illness.

We restore the body’s balance by periodically following a cleansing regimen. In Ayurveda, this is recommended at every change in season, but you can do this whenever you feel the need.

Since stress negatively impacts the digestive tract, reduce the amount of stress in your life by getting enough sleep and practicing meditation and other stress-relieving acivities.

Physical activity energizes both the digestive and immune systems. Engage in daily exercise, and don’t be afraid to sweat! Sweating opens up the pores and allows toxins to escape through the skin. Breathe deeply, and open up the lungs.

Treat yourself to a massage or visit a spa. Take a warm bath or shower every day. (Jacuzzis, steam baths, and hot tubs feel wonderful!)

Flush out your system with plenty of water, fruit juice, vegetable juice, and herbal tea. Dandelion root tea is especially beneficial in detoxifying the body.

Promote regular elimination by eating plenty of fresh fruits and vegetables. Add more fiber to your diet with whole grains and legumes.

Since this is a cleansing diet, avoid junk food, fatty food, processed food, sweets, soft drinks, alcohol, caffeine, and nicotine. Limit your intake of meat and dairy products.

Spice up your meals with liberal amounts of fresh herbs and spices. Cilantro, mint, lemon, basil, ginger, turmeric, cumin, coriander, clove, fenugreek, cinnamon, black pepper, and fennel whet the appetite and stimulate the digestive juices. Use extra-virgin olive oil whenever possible.

Prepare cool, light meals in summer and warm, nourishing meals in winter.

Follow this regimen for at least 30 days. People with chronic health problems or disabilities should consult a physician before making any diet changes or engaging in physical activity.

Dawn Pisturino, RN

2007; January 9, 2023

Published in The Kingman Daily Miner, June 7, 2007.

Copyright 2007-2023 Dawn Pisturino. All Rights Reserved.

Poetry Book Reviews: Kym Gordon Moore and Patricia Furstenberg

(Photo by John Jennings on Unsplash)

We are Poetry: Lessons I Didn’t Learn in a Textbook by Kym Gordon Moore (2022).

       Available on Amazon.com.

I’ve known Kym for about a year now and regularly follow her blog on WordPress. Although we don’t always agree, I’ve always found her to be intelligent, funny, well-educated, and articulate. And, she’s fierce! Whatever causes she embraces, she puts her whole heart and soul into them.

In her latest book, Kym provides a general overview of poetry and her vision for the future of poetry as an art form, a therapeutic tool, and an educational medium. She views poetry as a living, breathing thing that can transform the poet, the community, the country, and even the world. Poetry should be as rich, colorful, and diverse as life itself.

Her book is almost a textbook on creating poetry and would be a useful tool in the classroom. She introduces the concept of ArchiPoetry, which employs architectural ideas to design and perfect poetic creations. As she writes: “By combining the use of language, imagery, metaphors, and specific patterns, the design elements in ArchiPoetry have different disciplines and poetic variations.”

While journaling has been an accepted therapeutic tool for a while in mental health, Kym developed the concept of TheraPoetry, a process through which people can find emotional relief by expressing themselves with poetry. Kym speaks from experience. After the death of her mother, it was poetry – and writing poetry – which helped her through the grieving process.

Illiteracy is an issue about which Kym is very passionate; and she wants to use poetry as a medium to teach our children how to read and improve their reading comprehension skills. We all remember rhymes that we learned as children. Those rhymes stick in our heads as rhythmical pieces of our childhood, bring back fond memories, and encourage us to pass them on to the next generation.

Poetry is creativity, mental gymnastics, lyrical composition, and inner fantasy. Poetry is emotional release, mental growth, and spiritual expression. This is why Kym championed the cause of poetry in 2014 when she persuaded mayors all across North Carolina to submit proclamations officially recognizing April as National Poetry Month. Kym also endorses and supports the Academy of American Poets as a valuable resource for educators and poets everywhere. As she says, “Poetry is a revival and reminder of our aspirations, possibilities, and achievements for all people.”

Finally, I close with Kym’s own summation of poetry:

“Poetry paints emotion

art is imagination and passion

poetry inspires art

expressionism through creativity is art and poetry

-transformation-

poetry and art is creativity through expressionism

art inspires poetry

passion and imagination is art

emotion paints poetry.”

Website: From Behind the Pen

Christmas Haiku by Patricia Furstenberg (2018). Available on Amazon.com.

Patricia is a Romanian poet living in South Africa. Her poetry appears regularly on MasticadoresRomania, Spillwords Press, and other poetry sites and literary magazines. With Christmas right around the corner, I was drawn to read her book of Christmas haiku. Charmed by the simplicity of her verses and photos, I sincerely recommend this little chapbook as the perfect way to get into the candy-gingerbread-tinsel-lights holiday mood! Patricia has written numerous books for adults and children, which are all available on Amazon. So, grab a steaming cup of hot chocolate and enjoy!

“Christmas, snow, giggles,

Young and old around the tree.

Scent of fresh cookies.”

Website: Patricia Furstenberg, Author

Euthanasia and Healthcare Ethics: An Ethical Dilemma

A recent case of euthanasia in Europe prompted me to post this. Here’s the link to the case:

http://www.dailymail.co.uk/news/article-11291995/Woman-23-survived-2016-Brussels-airport-ISIS-bomb-euthanised-Belgium.html

(NOTE: Some laws may have changed since I wrote this in 2017.)

Euthanasia and Healthcare Ethics: An Ethical Dilemma

by Dawn Pisturino

Abstract

Healthcare ethics deal with life and death situations which involve every member of the healthcare team.  But the patient is at the heart of healthcare ethics, and the rights, safety, and well-being of the patient must come first in all healthcare decisions.  It is not up to healthcare personnel to decide who will live and who will die.

Euthanasia and Healthcare Ethics: An Ethical Dilemma

       Every discipline has a code of ethics to follow when it comes to making ethical decisions, and healthcare is no exception.  Ethics in healthcare is so important, in fact, that most organizations have a process through which tough ethical decisions, such as end-of-life decisions, can be made.

The Hippocratic Oath and Modern Healthcare Ethics

       The origin of healthcare ethics dates back to the Hippocratic School of 200 B.C. (Geppert & Roberts, 2008).  Hippocrates devised the Oath of the Hippocratic School, which includes confidentiality, nonmaleficence, and beneficence (Geppert & Roberts, 2008).  Since then, technology has forced changes in healthcare ethics, adding principles of autonomy, respect for persons, compassion, privacy, and honesty (Geppert & Roberts, 2008).  Most of these principles can be applied to end-of-life issues.

The End-of-Life Debate 

       The end-of-life debate has been fueled by the preponderance of chronic disease in modern society, quality of life issues, and the soaring cost of healthcare.  In most countries around the world, euthanasia and patient-assisted suicide are illegal.  Hippocrates himself said, “I will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to this effect” (Doukas, 1995).

Dr. Jack Kevorkian

       In 1999, Dr. Jack Kevorkian was found guilty of second-degree murder by a Michigan jury in the death of Thomas Youk (Charatan, 1999).  Dr. Kevorkian had administered a lethal dose of medication to Youk, who was suffering from ALS (amyotrophic lateral sclerosis).  He could not prove that Youk had asked him to end his life.

       The Hemlock Society, a proponent of physician-assisted suicide, condemned the verdict (Charatan, 1999).  But many organizations devoted to disability rights applauded Dr. Kevorkian’s conviction, claiming that euthanasia is a threat to people with disabilities (Charatan, 1999).  The American Medical Association issued a statement by Dr. Nancy W. Dickey, who was president at the time: “Patients in America can be relieved that the guilty verdict against Dr. Jack Kevorkian helps protect them from those who would take their lives prematurely” (Charatan, 1999).

       John Roberts, North American editor of the British Medical Journal, labeled Dr. Jack Kevorkian “a medical hero.”  He considered Kevorkian an honest man who was acting according to his personal moral principles (Roberts & Kjellstrand, 1996).  Still, most physicians want to be perceived by the public as healers – not death dealers (Doukas, 1995).

Dutch Euthanasia Act

       In 2002, the Netherlands passed the Dutch Euthanasia Act, sparking a world-wide debate on end-of-life issues (Van der Heide, 2007).

       Euthanasia, as defined in the Netherlands, is “death resulting from medication that is administered by a physician with the explicit request of the patient” (Van der Heide, 2007).  In physician-assisted suicide, the physician prescribes the medication and the patient administers it himself, leading to death.  In both cases, the physician is legally protected by the Dutch Euthanasia Act for ending life “at the request of a patient who was suffering unbearably without hope of relief” (Van der Heide, 2007).

       Before making a decision, physicians are required to discuss euthanasia and physician-assisted suicide with the terminally-ill patient and his relatives.  If there is any question about the ethical nature of the decision, physicians may discuss the matter with colleagues.  In 2005, in the Netherlands, 73.9% of all patient-requested deaths were the result of neuromuscular relaxants or barbituates; 16.2% were the result of opioids (Van der Heide, 2007).

Ethical Dilemma Case Example

       Physicians are not the only healthcare workers faced with ethical dilemmas.  Nurses also find themselves in situations where they must apply ethical principles.

       The Charge Nurse at a local hospital wanted to open up a patient bed in order to admit a patient from the emergency room.  She asked this author – the patient’s nurse – to give a dose of intravenous morphine to a patient who was dying of end-stage kidney disease.  Legally, the patient was a “Do Not Resuscitate.”  The family was at the bedside.

       “Ethical dilemmas often provoke powerful emotions and strong personal opinions; however, emotions and opinions alone are not a satisfactory way of resolving ethical dilemmas” (Lo, 2013).   Faced with an ethical dilemma of tantamount importance, this nurse had only a short time in which to make the right decision.

       The first thing to consider was the law and the legal ramifications of any decision made in this situation (Pojman & Fieser, 2017).  How would the decision affect the Charge Nurse and the patient’s nurse?  Would we be held legally liable if the patient died after receiving an extra dose of morphine?  Would we lose our nursing licenses?  Would the family sue?  Would we lose our jobs?  Euthanasia in Arizona is against the law.

       Secondly, would the patient want to be given an extra dose of morphine?  A “Do Not Resuscitate” status merely indicates that the patient does not want to be revived if the heart stops beating or respirations cease.  It is not a request for euthanasia.  Would it violate the patient’s personal or religious beliefs to administer an extra dose of morphine?  Would it violate her core ethics?  Would it take away her right of self-determination and autonomy (Pojman & Fieser, 2017)?

       Thirdly, to go into the patient’s room and administer an injection of morphine without just cause would violate the culture and ethics of the hospital, the doctor, and most of the nursing staff (Pojman & Fieser, 2017).  It would look suspicious to the family.  They would question what this nurse was doing.  It would place this nurse in an uncomfortable situation.

       The ethical dilemma posed here is this: should the patient’s nurse do what the Charge Nurse requested or refuse?  In order to make a rational and ethical decision, the patient’s nurse must first analyze the situation.  According to Pojman and Fieser, “most ethical analysis falls into one or more of the following domains: (1) action, (2) consequences, (3) character traits, and (4) motives.”

Action

       Giving the patient an extra dose of morphine would be the right action if the patient was in pain and wanted the medication.  It would be the right action if the patient seemed uncomfortable and the patient’s family requested it.  It would not be an obligatory act if it was too soon to give the medication or if the patient did not need it at that time.  It would be considered an optional act, based on the nurse’s professional judgment and opinion.  On the other hand, it would be a wrong action to give the morphine if the patient did not need it or the patient’s family did not want it given.  If euthanasia were legal and the physician was at the bedside and requested the patient’s nurse to draw up the medication, it would be considered a supererogatory act if the physician administered it to the patient.  He would be ending the patient’s suffering.  The nurse would be involved in a legal and compassionate act.

Consequences

       If the patient was in pain and needed the medication, giving the morphine would be the right action because it eased the patient’s pain.  If the patient died as a result, there would be no legal or professional consequences because there is no way to predict if that particular injection will cause the patient to stop breathing.  The morphine was given according to medical guidelines ordered by the physician.  If the patient was not in pain and the extra injection of morphine caused the patient to stop breathing, it could raise ethical and legal issues for the nurse who administered the medication.  Those issues would most likely be raised by the family, if they were concerned.

Character Traits

       The Charge Nurse was more concerned about opening up a patient bed than respecting the rights of the patient who was dying.  It seems callous, malevolent, and unfeeling.  The patient’s nurse must examine her own feelings and attitudes and decide if the Charge Nurse was right or wrong in her request.

Motive

       The motive of the Charge Nurse was clearly to give in to pressure from the emergency room to admit a patient.  She showed no concern whatsoever for the patient who was dying.  She had no respect for the patient’s rights and autonomy – or for the patient’s family.

       The nurse’s motive should be to protect the rights and safety of her patient.  She is the patient’s advocate.  If she gives in to pressure from the Charge Nurse, she will fail in her duty to her patient.  Even if she believes that euthanasia is a moral act, neither she nor the physician has informed consent from the patient or the family.

What Happened

       The patient’s nurse evaluated the motives of the Charge Nurse, felt disgusted, and went into the patient’s room to check on her condition.  She was resting quietly with her eyes closed, and the nurse saw no evidence of pain or discomfort.  When the nurse asked the patient’s family if they wanted the patient to receive a morphine injection for pain, they agreed with the nurse that the patient was resting quietly and did not need it.  Relieved, the patient’s nurse reported all of this to the Charge Nurse.  As a parting shot she added, “And I’m not Dr. Kevorkian!”

Conclusion

       Patients and their families have the final say in what happens to terminally-ill patients.  It is not up to healthcare personnel to make decisions about end-of-life care for a patient.  This will be particularly true if euthanasia and patient-assisted suicide ever become legal on a widespread scale.  The medical community, in line with its own ethical principles, must respect the right of self-determination and autonomy of terminally-ill patients.

References

Charatan, Fred. (1999). Dr. Kevorkian found guilty of second degree murder. British medical

       journal, 318(7189), 962. Retrieved from

       http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1174693/

Doukas, D.J., Waterhouse, D., Gorenflo, D.W., Seid, J. (1995). Attitudes and behaviors on

       physician-assisted death: A study of Michigan oncologists. Journal of Clinical Oncology,

       13(5), 1055-1061

Geppert, M.A., & Roberts, L.W. (Ed.) (2008). Book of ethics. Center City, MN: Hazelden

       Foundation

Lo, Bernard. (2013). Resolving ethical dilemmas: A guide for clinicians. Philadelphia, PA:

       Lippincott, Williams and Wilkins

Pojman, L.P., & Fieser, J. (2017). Ethics: Discovering right and wrong. Boston, MA:

       Cengage Learning

Roberts, J., & Kjellstrand, C. (1996). Jack Kevorkian: a medical hero. BMJ: British

       Medical Journal, 312(7044), 1434

Van der Heide, A., Onwuteaka-Philipsen, B.D., Rurup, M.L., Buitina, H.M., van Delden, J.M.,

       Hanssen-de Wolf, J.E., . . . van der Wal, G. (2007). End-of-life practices in the Netherlands

       under the euthanasia act. New England Journal of Medicine, 356 (19), 1957-1965.

~

UPDATE:

Where is assisted dying legal in Europe? 

Assisted dying refers to both voluntary active euthanasia and physician-assisted death, when a patient’s life is ended at their request. 

Only three countries in Europe approve of assisted dying as a whole: Belgium, the Netherlands, and Luxembourg.

 The first two even recognise requests from minors under strict circumstances, while Luxembourg excludes them from the legislation.

 Germany, Switzerland, Germany, Finland, and Austria allow physician-assisted death under specific circumstances. 

Countries such as Spain, Sweden, England, Italy, Hungary, and Norway allow passive euthanasia under strict circumstances. Passive euthanasia is when a patient suffering from an incurable disease dies because doctors stops doing something necessary to keep them alive. 

Sources: Euronews

~

Dawn Pisturino

Philosophy 151

May 2, 2017; November 2, 2022

Copyright 2022 Dawn Pisturino. All Rights Reserved.

The Many Paths of Yoga

Yoga is a Sanskrit word meaning union or communion. The purpose of practicing yoga is to achieve oneness with the Supreme Universal Spirit.

Yogis view the universe as an emanation of God’s love, and they see His essence in all things. Through the serious practice of yoga, they learn to realize the divine source within themselves, transcend the material world, and become one with the Divine Power.

Yoga encompasses many paths.

Karma Yoga– the path of action – involves attaining enlightenment and unity through selfless service to others without any expectation of reward. 

Bhakti Yoga– the emotional path – requires total absorption in a personal deity and is marked by intense love and devotion, and deep prayer and meditation.

The intellectual path is called jnana yoga, which emphasizes the study of sacred scripture and ancient wisdom.

Hatha yoga is concerned with physical self-discipline through the diligent practice of asanas, or postures. This form of yoga has become very popular in the West over the last few decades.

These postures were developed over thousands of years to exercise the muscles, nerves, and glands. They tone the body, increase flexibility, help to eliminate toxins, stimulate the release of hormones, and promote mental, physical, and spiritual balance.

People who consistently practice these postures report greater levels of energy and vitality, lightness of body, mental clarity, and a heightened sense of well-being. With persistence, they develop discipline of both mind and body, deeper spiritual awareness, and a sense of unity with the Divine.

Raja yoga literally means “king yoga” and is considered the supreme path, for it seeks both mental and spiritual discipline. Raja yogis struggle to purify and perfect their minds, bodies, and spirits through constant practice of yogic principles, including all the paths of yoga mentioned above. Yogis who succeed are regarded as saints. They are recognized by their profound love for humanity, their wisdom, their power to relieve suffering, and the feelings of peace and serenity which they bring to others.

~

Dawn Pisturino, RN
March 2, 2007; September 26, 2022
Copyright 2007-2022 Dawn Pisturino. All Rights Reserved.

The Amazing Apple

(Photo by Vera De on Unsplash)

The Amazing Apple

by Dawn Pisturino

Hooray for the all-American apple! Boiled, baked, stewed, juiced, fried, dried, or raw, apples are as American as rock-and-roll.

Eating this amazing little fruit is one of the simplest ways to improve and maintain good health at a reasonable cost.

Apples are high in fiber, which is important for eliminating toxins from the body, lowering cholesterol, and regulating blood sugar, appetite, cell growth in the colon lining, and the action of bile acids in the body.

Apples are a great source of antioxidants because they contain vitamin C and a phytonutrient called quercetin. Quercetin is a flavonoid which is currently being researched for its anti-cancer properties, especially against lung and prostate cancer.

There is only about 10 mg of vitamin C in an average apple, but when combined with the quercetin, research has shown that the effects in the body are equivalent to 1500 mg of vitamin C. Now, that’s powerful stuff!

Apples have been proven to have antiviral, antiseptic, and laxative properties, contain a natural sugar called sorbitol, and a wide variety of important vitamins and minerals.

Researchers believe that regular consumption of apples can improve lung function, lower the risks of cancer, heart disease, and stroke, contribute to weight loss, and protect the brain from degenerative diseases such as Alzheimer’s.

The Washington Apple Commission recommends eating at least one apple a day in order to reap these benefits.

Cooked apples are easier to digest than raw ones. Apple juice — especially freshly pressed — has almost the same benefits as the whole apple.

Apples are a traditional part of the school lunch box. In the kitchen, apples combine well with other fruits and vegetables.

For free recipes and more information, go to the Washington Apple Commission website at

http://www.waapple.org

Dawn Pisturino, RN

February 25, 2007; September 16, 2022

Published in The Kingman Daily Miner, June 26, 2007.

Copyright 2007-2022 Dawn Pisturino. All Rights Reserved. 

Jesus Met the Woman at the Well

(Photo from http://www.Christ.org)

[Note: All quotations are from the New King James Version Bible]

John 4:1-54 in the New Testament tells the story of the woman at the well. When Jesus informed his disciples that he was going to go to Galilee by way of Samaria, they would have been surprised, although John does not tell us so. Samaria was generally avoided by devout Jews. Interactions with Samaritans were frowned upon due to religious and cultural conflicts. Jesus was making a daring move and a profound statement by choosing to go there.

Jesus traveled to the city of Sychar and decided to rest at Jacob’s Well, which was just outside the city, while his disciples went on to procure food. Soon, a Samaritan woman came to the well to draw water. When Jesus asked her for a drink of water, she reminded him that Jews did not mix with Samaritans. But Jesus offered her “the gift of God” and “living water” in exchange for the drink.

The woman questioned Jesus further, reminding him that Jacob dug the well. But Jesus pointed out to her that ordinary water would always leave a person thirsty. The water he offered would give “everlasting life.” The woman, intrigued, asked for her portion of this water, but Jesus turned the tables on her by asking her to bring her husband to the well. The woman admitted that she had no husband.

Jesus, pleased by her honesty, revealed that she had had five husbands. The woman, amazed by his knowledge of her, honored him as a prophet. She reminded Jesus that part of the conflict between the Jews and the Samaritans was the sacred places of worship, which differed between the two groups. Jews believed Jerusalem was the only place to properly worship God, and the Samaritans worshipped right there on the mountain near Jacob’s Well.

In response, Jesus made a profound admission. “The hour is coming, and now is, when the true worshippers will worship the Father in spirit and truth; for the Father is seeking such to worship Him. God is spirit, and those who worship Him must worship in spirit and truth.” He seems to be saying here that God does not need a temple or particular place in which to be worshipped. Worship comes from the heart and the soul and cannot be contained within brick-and-mortar walls or special designated places of worship. God is everywhere and all-inclusive. All people are welcome to worship Him.

The woman at the well affirmed her belief in the coming of the Messiah, and Jesus admitted that He was the Messiah. The disciples returned then with the food and did not question Jesus talking to the Samaritan woman. But Jesus affirmed to them that He was doing His Father’s work – that was His real food.

In her excitement, the woman ran off without her water jug. But she no longer needed it because she had heard Jesus’s words and left filled with the Holy Spirit. She informed the city about Jesus and His wise words. People flocked to hear what He had to say. Many believed in Him because of what He had to say. People told the woman, “we know that this is indeed the Christ, the Savior of the World.”

After two days, Jesus and His disciples traveled on to Galilee. He returned to Cana, where he learned about a wealthy man’s son in Capernaum who was sick. Jesus admonished the people, accusing them of not believing in Him unless they “see signs and wonders.” But Jesus reassured the father that his son would live. When the man returned home, he learned that his son had recovered from his illness at about the same time that Jesus had assured him that his son would live.

The difference between the Samaritans and the Galileans was that the woman at the well and the people in Sychar believed in Jesus as the Christ because of His words, whereas the Galileans wanted proof in the form of miracles.

May we listen to the words of Jesus and find comfort in His wisdom, love, and compassion. May we put all of our trust in God and hand over all of our worries and cares to Him.

(Folk singers Peter Yarrow, Paul Stookey, and Mary Travers: “Jesus Met the Woman,” from the 1964 album, “Peter, Paul, and Mary in Concert.”)

Dawn Pisturino

August 26, 2022

Copyright 2022 Dawn Pisturino. All Rights Reserved.