Mary Thomann Rosemary Mason-Blau Joselyne Colindres Barbara Rousseau Sarah Blanchette Making Healthcare Decisions for Others: A Case Study on Schizophrenia

What is Schizophrenia?  Schizophrenia is a chronic, severe, and disabling brain disorder.  It currently affects about 2.2 million American adults and 24 million people worldwide.  More than 50% of those with schizophrenia are not getting proper treatment. (W.H.O.) Sarah Blanchette

The Case A Patient Named Jane  Diagnosed with disorganized schizophrenia in early twenties.  The prescription medication, Clozapine, has been effective in treating her symptoms for about 15 years.  When the meds are working, Jane feels like she is cured and sometimes decides to stop taking them.  When off the meds she becomes delusional, and hears voices telling her to hurt herself.  Believes the medication is poisonous and that her doctor is out to get her. Sarah Blanchette

The Ethical Dilemma  Jane’s family wants her to take the medication because they feel that she may try to harm herself again without it.  The family never discussed the situation with Jane before but believe that if she was in the right state of mind that she would agree to take the medication.  Jane may require being hospitalized against her wishes in order to receive proper medical care. Sarah Blanchette

Danger to Self  What are the ethical considerations of making a decision for another person when they are a danger to themselves? Here are 3 scenarios: Mary Thomann

Danger to Self Mary Thomann 1.The person could be mentally ill but still retain the capacity to make decisions about health care. 2.The person could be mentally ill but lack the capacity to make decisions about health care. 3.The person could be mentally ill without decision making capacity at the present time, but during an earlier time, had decision-making capacity and indicated she did not wish to be confined.

Danger to Self Mary Thomann Ethical considerations:  Autonomy (self-determination) vs. protection (beneficence)  If the mentally ill person does not presently have decision- making capacity, are their advance directives that indicate what they would want and name a proxy?  If it is determined that the mentally-ill person should be confined in spite of her wishes to the contrary, it is best if that time is short and temporary.

Danger to Self Mary Thomann  In summary, there is seldom justification for the involuntary confinement of a patient suffering from any illness, mental of physical – if the person has decision-making capacity or, if he does not now have this capacity, once had it and made it clear that he did not want confinement.

Informed Consent : Standards of Decision Making  Gold Standard: Documentation of the patient’s preference such as Living Will or A.D.  Silver Standard: Substitutive Judgment. The patients family or guardian decides what the patient would want based on what they know of the patient.  Bronze Standards: The courts decide what is in the best interest of the patient. Rosemary Mason-Blau

HEALTHCARE DIRECTIVES  Your wishes for medical treatment made in advance in case you become unable to express your wishes.  Healthcare providers are held to strict standards to comply with your wishes. Some Exceptions can include:  Goes against the conscience of the Dr. or medical provider  Goes against the hospital’s policies or other medical institution based on reasons of conscience  Decisions that would result in ineffective healthcare or asking healthcare providers to adopt healthcare standards that violate those of the provider Barbara Rousseau

 Usually for end of life decisions  Only for healthcare decisions, not for property or possessions  Can be very general or very specific  Examples of specific include  DNR  Life prolonging medical care  Life prolonging food and water  Pain management  Should also have Power of Attorney Barbara Rousseau Living Will

Power of Attorney for Healthcare  When you put someone you trust in charge of making your healthcare decisions not covered in your Living Will  Your appointed agent cannot overrule your wishes in your Living Will, but they can supplement your wishes if something comes up that wasn’t listed in your Living Will Barbara Rousseau

 Must prove beyond reasonable doubt that the proposed ward cannot provide basic needs such as food clothing and shelter  Can be emotionally difficult if it is a family member to prove that they are incapacitated 3 Types of Guardianship  Guardian over person  Guardian over estate  Guardian over person and estate Barbara Rousseau Legal Guardian

Ethical Case Analysis Process Step 1Gather all information  Medical Indications  Patient Preferences  Quality Life  Contextual Factors Rosemary Mason-Blau

 Diagnosed in early 20’s  Has been taking Clozapine, seems to work on symptoms  When off her meds becomes delusional  When she hears voices, they sometimes tell her to hurt herself  She has attempted suicide on at least 2 occasions when off medication Step 1 Rosemary Mason-Blau

Ethical Case Analysis Process Step 2Identify Source of Conflict Rosemary Mason-Blau The obvious sources of conflict here are Jane’s doctor and Jane’s family. Both want to Jane to be on her medication and receive medical care but in her current state of mind, Jane does not agree.

Ethical Case Analysis Process  The courts have found Jane to be incapable of making decisions regarding her own healthcare.  The judge appoints Jane’s sister, Kate, as legal guardian over Jane. Rosemary Mason-Blau

Ethical Case Analysis Process Step 3Identify Primary Persons  Patient/Family  Health Care Providers  Religious/Cultural Rosemary Mason-Blau

Step 3  The Primary people in this case study are Jane, Jane’s immediate family and Jane’s physician.  Jane feels strongly that she does not want to take her medication. Everyone else involved has the opposite opinion and wants to see Jane receive medical treatment.  No religious or cultural influences are present in this case. Rosemary Mason-Blau

The Case continued:  Kate, as Jane’s guardian, petitions the courts to have Jane committed to a mental health facility where she will receive her medication regularly as well as receive psychiatric care.  Kate’s request is granted and Jane is sent to the Elliot Hospital in Manchester. There she will be an inpatient of the behavioral health department until it is deemed that she can be released to the care of her guardian. Rosemary Mason-Blau

Ethical Case Analysis Process Step 4Determine the Best Method for Resolution  Communication  Conflict Management Joselyne Colindres

Conflict Management  Address all facts of the case  Address all emotional factors and common interests  Weigh benefits and risks of treatment options  Design a clear plan of action designed by primary person and acceptable to primary persons  Document the plan  Reevaluate and follow up Joselyne Colindres

Emotional factors are :  Jane is insistant that she does not want to be medicated.  Jane’s family knows that the medication is the best option for her but feel bad going against her wishes. Common interests are:  Everyone wants what is best for Jane. Joselyne Colindres

Step 4 continued Treatment options are: 1. Medicate Jane 2. Allow Jane to go un-medicated Benefits of medication:  Symptoms are under control: Jane is not paranoid or delusional  Jane does not try to commit suicide to escape the voices Risks of medication:  drowsy feeling  agranulocytosis (decreseased WBC’s and suppressed immune system) Joselyne Colindres

Clear Plan of Action  The plan of action is to have Jane committed to an institution where she will be medicated and under the care of physicians.  This plan of action is acceptable to all primary persons except Jane, who is found to be incapable of making decisions for herself.  The plan will be documented and if necessary, the plan will be reevaluated and redesigned. Joselyne Colindres

Ethical Case Analysis Process  According to the ethical case analysis process we find that Jane’s family and physician acted in an ethical way when they petitioned to have a guardian assigned.  The courts acted ethically by deciding to have Kate handle Jane’s medical decisions and by involuntarily committing Jane.  The benefits of Jane receiving proper medical treatment against her wishes outweigh the risks.  Jane’s family is doing what is ethical and what is in the best interest of their sister and daughter. Joselyne Colindres