Case Presentation:
A 77‐year‐old male with paranoid schizophrenia was admitted with recurrent ascending cholangitis and gram‐negative bacteremia. Three months earlier, he was diagnosed with pancreatic adenocarcinoma with wide metastases to the liver. Prior to his terminal cancer diagnosis, the patient lived independently and received no treatment for his psychosis. While hospitalized, he continued to be psychotic with auditory hallucinations, intermittent refusal of care, and episodes of extreme agitation, for which he treated with antipsychotic medications. Throughout his hospital course, the patient denied he had any kind of malignancy and perseverated on going home. He expressed understanding that the medical team diagnosed him with cancer, but he simply did not believe the diagnosis. In addition, he refused to address treatment options, palliative care, or hospice, resulting in multiple hospital admissions for abdominal pain, anorexia, and jaundice. Due to his lack of insight, he was determined to lack decision‐making capacity, and a short‐term mental health certification was obtained. Complicating the situation, the patient had no family, friends, or interested parties to act as health care proxy. Once medically stabilized, the patient was transferred to the inpatient psychiatric service and maintained on antipsychotic medications. After several weeks of treatment, he came to understand that he had terminal cancer and opted for comfort care, all the while requesting to go home. He was ultimately discharged to a nursing home with hospice and passed away shortly thereafter.
Discussion:
Hospitalists routinely assess decision‐making capacity in their patients. This case demonstrates the difficulty of managing a patient without capacity who has terminal illness and no surrogate decision‐maker. Mental health certifications, like all medical decisions, should be guided by the principles of medical ethics: autonomy, justice, beneficence, and nonmaleficence. It is within the ethical code that if a patient lacks the capacity to make medical decisions autonomy of the patient is withdrawn, though not disregarded. The principle of justice states that the decision must be applied the same to all patients, without favoring one group or disregarding another. In other words, all patients should be treated the same under the same circumstances. The decision to place a mental health certification is routinely conducted when patients are determined to lack capacity. Therefore making this decision for this patient was consistent with regulations and just. The principles of nonmaleficence and beneficence direct that the medical decision should not cause harm and should provide benefit, respectively. Examining theses principles raises the question, did this patient experience benefit or harm by having forced medical therapy? Perhaps this patient suffered more because ignorance of a terminal diagnosis would have protected him from the fear of death. On the other hand, he may have benefited by gaining insight into his condition, which may have averted suffering from misunderstanding of changes in his body and the source of his pain.
Conclusions:
Although lack of capacity has a strict medico‐legal definition, the decision to place patients who lack capacity, and do not have any other surrogate decision‐makers, on mental health certifications should not be made routinely, but rather should be done with strict consciousness of the principles of medical ethics.