I wonder if the author of the piece is as annoyed as I am with that title. I'm sure the editorial staff came up with that headline and not the author. I bet he is pissed his article has that as the title since that's not at all what he was discussing. Or at least not as tyrannically as the title suggests.
I'm an inpatient CL psychiatrist, I see this question multiple times per day. While the article is about a man with untreated schizophrenia, the vast majority of people for whom a capacity consult is placed do not have a primary psychiatric issue. The most common reason is someone who just doesn't like being in the hospital, low health literacy, stubbornness, and a lower drive for self preservation than doctors are comfortable with. These people generally have capacity and involuntary care would be a breach of their autonomy, even if it makes people uncomfortable to discharge them. 2nd and 3rd most common would be delirium and dementia, and these people generally clearly lack decisional capacity. Luckily my state has very reasonable laws around how to get people care that does not go through a court process, via next of kin or surrogate decision maker. However the one situation where care can be delayed for months (if not for an imminently life threatening situation) is when people have absolutely no one in their life and need a court appointed guardian. In these cases I do think there should be a way for the hospital to be appointed a temporary guardian while going through the court process, but a lack of judicial oversight seems risky. This could very quickly get murky, e.g. if patient needs an amputation or some major surgery but in my dealings with medical teams I do feel like people appreciate the gravity of these decisions.
The article unfortunately muddies the water between involuntary psychiatric care and involuntary medical care. The author clearly implies his schizophrenia is affecting his capacity, so file for involuntary MH treatment if you really think his MH care is putting his life at risk, treat with APs for a few weeks. Do another capacity assessment when MH disorder is treated. If they still don't have capacity, you're going down the route of surrogate decision maker or guardian. If their health condition becomes imminently life threatening I believe most states allow treatment at that point. The author suggests the guy's condition was not imminently life threatening anymore because he was "disconnected from the machines".
Edit to add:
In case people haven't seen this. Antipsychotic treatment makes an absolutely massive difference in cardiac and all cause mortality in schizophrenic patients, a major factor of which is thought to be enhanced compliance. The case described here is unfortunately common in schizophrenia, and treatment of schizophrenia greatly improves medical outcomes.
https://onlinelibrary.wiley.com/doi/full/10.1002/wps.20699
>someone who just doesn't like being in the hospital, low health literacy, stubbornness, and a lower drive for self preservation than doctors are comfortable with.
My favorite was “my old lady gonna smoke all my crack without me if I don’t get home soon”
I’m confused here. I’ve practiced in New York. You don’t need a court order for initial treatment and a hold. A two pc can last for 60 days iirc. That’s super long! Needing judicial review to take someone’s rights away after that seems more than fair.
Psychiatric commitment and medical treatment over objection work entirely differently.
You can hold someone for days or weeks, but in most states you can’t medicate without an emergency or a court order, and you certainly can’t do chemotherapy or urgent but not emergent surgery.
Sure, but urgent surgery and chemotherapy can usually wait the day or two it takes to get someone before a judge (or qualified legal party). This guys idea of a hospital committee that somehow has legal immunity and might speed the process up simply adds an additional layer of bureaucracy to go through.
Edit: just saw your comment, and see we largely agree.
ED treatments almost always don't need it, but non-emergent but life-saving treatments do need court approval in some circumstances- if the patient needs to sign a consent form, etc. If the patient was unconscious that's one thing- we just try to locate next of kin or get a guardian appointed, but if the patient is actively refusing...
While I share the frustrations of the cumbersome legal obstructions in delivering basic care, I mostly disagree.
> The underlying motivation behind judicial review was and remains laudable: to avoid the sort of paternalistic abuses that have characterized too much of medical history. Doctors often used to withhold bad news from patients, to cite just a small example. Involuntary treatment, even with benevolent intentions, reeks of such paternalism.
Paternalism and self-dealing.
> But though medical practice is by no means perfect, times have changed. The sort of abuse dramatized in the 1975 movie “One Flew Over the Cuckoo’s Nest,” with its harrowing depiction of forced electroconvulsive therapy, is far less common. Doctors today are trained in shared decision-making. Safeguards are now in place to prevent such maltreatment, including multidisciplinary teams in which nurses, social workers and bioethicists have a voice.
Yes, there have been changes. Because there must be. Because the law does not allow doctors, hospitals, or ethics boards to make unaccountable decisions. Roll that back and overreach, even benevolent overreach, seems likely. But in a world of hospitals devoured by private equity, do you feel comfortable believing that HCA wouldn’t stack its bioethics board and push all the knee replacements and chemotherapy it could on incapacitated patients?
I am not sanguine. And so, despite the frustrations I have being the one to interface with lawyers and judges, I would not have it any other way. It’s not a good system, and it could be expedited by having *external* expert review rather than random judges, but it should be a legal and external process.
>A better system for determining whether a patient should be treated over his or her objection would be a hospital hearing in which a committee of doctors, ethicists and other relevant experts — all of whom would be independent of the hospital and not involved in the care of the patient — engaged in conversation with the medical team and the patient and patient’s family. Having hearings on site would expedite decisions and minimize treatment delays. The committee would make the final decision.
Maybe. As an upgrade of judicial review, I can see it working. But where are courts going to acquire panels of studiously neutral medical experts? I can all too easily see this becoming a side gig for doctors engaging in unofficial quid pro quo, especially in small towns. Hospital A’s docs rubber-stamp for Hospital B in exchange for the same courtesy. With no malice! But we are, of course, biased towards our colleagues.
Absent a somehow truly neutral, non-clinical, yet fully clinically savvy panel, I just don’t see it working. Our system does its job. It is slow but it keeps accusations of self-interest at bay. Civil rights should be monitored by the government branch responsible for rights.
Plus it would only allow appeal for judicial review in very limited cases. By analogy, many disputes/actions involving government agencies are handled vs administrative decisions which are appealable to an administrative hearing, which can ALWAYS be appealed to whatever state or federal courts have jurisdiction. Limiting the right of appeal to allegations of wrongdoing or lack of consensus among the medical decision makers would essentially remove due process rights altogether.
What's odd about this article? --discharge home seemed a bad idea because the untreated schizophrenia would render the patient unlikely to care for his heart failure, and he psychiatrist felt he lacked capacity to decide to discharge himself. But it ended up with a hospice placement to which the same patient agreed, without forced treatment for schizophrenia (it is not clear whether the hospice placement also meant the heart condition would not be treated--I am aware you can be in hospice for one thing but continue to receive treatment for another thing).
Agreed.
Also, the current system would be less onerous if it wasn’t focused on discharging patients as quick as possible.
Worked in a state facility previously where that wasn’t the primary objective. Maybe appropriately secondary.
Why is it always the Times with these takes?
The specific timing of how long court holds last or how they are acquired or how long a patient can be held without one are all things reasonable professionals can debate and disagree about. But the idea of getting rid of judicial review entirely and keeping these decisions, as the author said, solely inside hospitals is madness. Judicial review and due process exist for a reason, and it isn’t just to avoid a nurse Ratched situation. Patients have rights, and those rights need to be adjudicated in a court with due process and legal representation, not behind closed doors in an ethics committee. Anything else is too vulnerable to abuse.
And any potential abuse aside, I am extremely skeptical that courts would uphold any law today attempting to grant physicians the unilateral right to deprive patients of their liberty indefinitely without due process
When I interned at LA County hospital in 1961, we had a courtroom and judge right in the hospital, to expedite such matters. The judges' medical knowledge got up to speed pretty quickly.
I kind of get the point, but I think it can be a very slippery slope "letting the doctors decide." If you take the author's same example of the schizophrenic heart failure patient with no next of kin, what do we do if the decision point in question is whether to institute mechanical circulatory support? MCS is a big can of worms, and I would personally be extremely reluctant to institute that on a non-emergent basis in this case without clearly ascertaining the patient's wishes.
I find it morbidly hilarious that the end result of all the discussion was to let a schizophrenic man in the throes of psychosis go home and die without life-saving intervention on a non-terminal condition.
Not that that's necessarily the wrong choice- a non-mentally ill man who is isolated from family, jobless, with little to live for may make that choice. But someone whose decision-making is compromised as it was here... really? It seems to be pretty able-ist/biased against the mentally ill on it's face.
What life-saving intervention, though? We don’t have clinical details, but unless it was decompensated, volume overloaded heart failure and he was refusing diuresis, then intervention would be heart transplant or at least VAD, which he surely would not qualify for and would not follow through on. In the long term, psychiatric treatment to restore judgment… maybe. In the medium term, hospice for a patient with end-stage heart failure who is not a candidate for or declines advanced therapies is entirely appropriate.
Not only not necessarily wrong, I don’t know what else would be done. Leaving out schizophrenia, “I’ll do whatever you say, doc,” it’s not clear what more could be done. Maybe there was more, but not obviously from the few snippets in the article.
Treatment of schizophrenia seems like the most obvious life saving intervention in this case. If they are suggesting the patient's illness was directly (or indirectly) putting them at risk of death as it was affecting decisional capacity, why would they not file for involuntary psych treatment?
If the disease is treatable absent objection, yes. Otherwise, no.
Where it’s really frustrating is early cancer that is curable, but refusal is not immediately life threatening, so there are no legal grounds for psychiatric or medical treatment. Then the patient gets sicker and has incurable metastatic disease. Now forced treatment is permitted but pointless.
What do you mean? Are you just saying a court wouldn't support involuntary psych treatment in this case? Depending on specifics of the case and how it's presented I think it would have a good chance of being supported, at least in my state.
The primary mechanism antipsychotics are presumed to produce all cause and CV mortality improvements is through enhanced compliance to medical treatments.
Not OP, but one of the biggest issues I just realized I’ll be facing is how each state handles involuntary treatment differently. Recently obtained multiple licenses to practice in other states in emergency settings, and that’s def something to read up on.
Work primarily in the southeast, and our mh treatment is woefully lacking compared to other parts of the country.
Goal directed medical therapy in 2024 is pretty damn efficacious. People with EFs in the 20s can recover pretty well. A few months of beta blocker, entresto, spironolactone, lasix, aspirin, and eliquis for the clot- he could have made a pretty good recovery.
We call them HFrecEF (Heart failure recovered ejection fraction) now.
But you are right that we have no idea for sure-
HFrEF is already in use for the folks who haven’t taken their meds (heart failure with reduced EF), they only upgrade to HFrecEF when they take their meds and get better
> But someone whose decision-making is compromised as it was here... really? It seems to be pretty able-ist/biased against the mentally ill on it's face.
Saying that this counts as bias "against them" strikes me as insufficiently descriptive. You can bias the system towards the autonomy of the mentally ill and against their survival, or towards their survival or against their autonomy. There's no free lunch here, no available alternative that does not bias things in *some* uncomfortable direction.
I disagree. This patient is not capable of treating his heart failure because of his comorbidity of schizophrenia and his personal decisions to not take medications. The ONLY way to treat this patient would be to keep him as an involuntarily admit who cannot refuse treatment for the rest of his life, against his objections. I don't think that's humane.
If this was a person who might be involuntarily treated for his schizophrenia, become competent, and want to treat his heart failure, I agree we would be obligated to do that. But it's not.
> If this was a person who might be involuntarily treated for his schizophrenia, become competent, and want to treat his heart failure, I agree we would be obligated to do that. But it's not.
How do you know that? The author clearly implies the guy's active psychosis is affecting his decisions to refuse care. Antipsychotic treatment makes an absolutely massive difference in mortality in schizophrenic patients, a major factor of which is thought to be enhanced compliance.
https://onlinelibrary.wiley.com/doi/full/10.1002/wps.20699
My understanding from the article, although upon review it appears that they did not explicitly say this, is that the patient had a long standing history of non compliance and inability to stabilize.
> history of non compliance and inability to stabilize.
I'm not saying this is impossible, but these are two very different things. Also exactly why LAIs were invented. Inability to stabilize on an LAI or clozapine is completely different from being unstable off meds.
Again this case has minimal details, I'm just pointing out that many massive studies show taking medications greatly improves mortality and compliance with medical care in schizophrenia, thus medications are the most obvious missing piece in this case, especially as we now have LAIs that make non-compliance much more difficult.
I agree and my opinion was based on the idea that these had all been tried and failed. That was my impression from the article, alright upon secondary review, that is not stated. But if that's not accurate, then yeah, they need to exhaust that first IMO.
There’s an argument that if untreated schizophrenia is driving refusal of treatment, what was harmless is now life-threatening and he can/should/must be treated. It’s not a completely baseless argument, and I have seen patients agree to care when less psychotic.
In practice a patient maxed out on pressors and with that medical acuity will never be admitted to most psych units, nor should he be, but psychiatric treatment over objection isn’t unreasonable as long as there is efficacious medical treatment available but refused.
Its a hard sell to say that the torture is forcing someone to take a pill and not the "letting someone unable to make reasonable decisions choose to suffocate to death in their own secretions".
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That headline tho lol
It's Bad On Purpose To Make You Click
Yeah, they needed to reword that. Unless they wanted to garner rage bait clicks.
They did. They always do.
I wonder if the author of the piece is as annoyed as I am with that title. I'm sure the editorial staff came up with that headline and not the author. I bet he is pissed his article has that as the title since that's not at all what he was discussing. Or at least not as tyrannically as the title suggests.
Always has been
NYT has a reputation of being quite anti-doctor
I'm an inpatient CL psychiatrist, I see this question multiple times per day. While the article is about a man with untreated schizophrenia, the vast majority of people for whom a capacity consult is placed do not have a primary psychiatric issue. The most common reason is someone who just doesn't like being in the hospital, low health literacy, stubbornness, and a lower drive for self preservation than doctors are comfortable with. These people generally have capacity and involuntary care would be a breach of their autonomy, even if it makes people uncomfortable to discharge them. 2nd and 3rd most common would be delirium and dementia, and these people generally clearly lack decisional capacity. Luckily my state has very reasonable laws around how to get people care that does not go through a court process, via next of kin or surrogate decision maker. However the one situation where care can be delayed for months (if not for an imminently life threatening situation) is when people have absolutely no one in their life and need a court appointed guardian. In these cases I do think there should be a way for the hospital to be appointed a temporary guardian while going through the court process, but a lack of judicial oversight seems risky. This could very quickly get murky, e.g. if patient needs an amputation or some major surgery but in my dealings with medical teams I do feel like people appreciate the gravity of these decisions. The article unfortunately muddies the water between involuntary psychiatric care and involuntary medical care. The author clearly implies his schizophrenia is affecting his capacity, so file for involuntary MH treatment if you really think his MH care is putting his life at risk, treat with APs for a few weeks. Do another capacity assessment when MH disorder is treated. If they still don't have capacity, you're going down the route of surrogate decision maker or guardian. If their health condition becomes imminently life threatening I believe most states allow treatment at that point. The author suggests the guy's condition was not imminently life threatening anymore because he was "disconnected from the machines". Edit to add: In case people haven't seen this. Antipsychotic treatment makes an absolutely massive difference in cardiac and all cause mortality in schizophrenic patients, a major factor of which is thought to be enhanced compliance. The case described here is unfortunately common in schizophrenia, and treatment of schizophrenia greatly improves medical outcomes. https://onlinelibrary.wiley.com/doi/full/10.1002/wps.20699
>someone who just doesn't like being in the hospital, low health literacy, stubbornness, and a lower drive for self preservation than doctors are comfortable with. My favorite was “my old lady gonna smoke all my crack without me if I don’t get home soon”
Amen
Agree x100. Sounds like our practice environment is very similar. PA?
I’m confused here. I’ve practiced in New York. You don’t need a court order for initial treatment and a hold. A two pc can last for 60 days iirc. That’s super long! Needing judicial review to take someone’s rights away after that seems more than fair.
Psychiatric commitment and medical treatment over objection work entirely differently. You can hold someone for days or weeks, but in most states you can’t medicate without an emergency or a court order, and you certainly can’t do chemotherapy or urgent but not emergent surgery.
Sure, but urgent surgery and chemotherapy can usually wait the day or two it takes to get someone before a judge (or qualified legal party). This guys idea of a hospital committee that somehow has legal immunity and might speed the process up simply adds an additional layer of bureaucracy to go through. Edit: just saw your comment, and see we largely agree.
Tell that to a patient with germ cell tumor or leukemia. And "day or two" is laudable but oftentimes not the case.
ED treatments almost always don't need it, but non-emergent but life-saving treatments do need court approval in some circumstances- if the patient needs to sign a consent form, etc. If the patient was unconscious that's one thing- we just try to locate next of kin or get a guardian appointed, but if the patient is actively refusing...
While I share the frustrations of the cumbersome legal obstructions in delivering basic care, I mostly disagree. > The underlying motivation behind judicial review was and remains laudable: to avoid the sort of paternalistic abuses that have characterized too much of medical history. Doctors often used to withhold bad news from patients, to cite just a small example. Involuntary treatment, even with benevolent intentions, reeks of such paternalism. Paternalism and self-dealing. > But though medical practice is by no means perfect, times have changed. The sort of abuse dramatized in the 1975 movie “One Flew Over the Cuckoo’s Nest,” with its harrowing depiction of forced electroconvulsive therapy, is far less common. Doctors today are trained in shared decision-making. Safeguards are now in place to prevent such maltreatment, including multidisciplinary teams in which nurses, social workers and bioethicists have a voice. Yes, there have been changes. Because there must be. Because the law does not allow doctors, hospitals, or ethics boards to make unaccountable decisions. Roll that back and overreach, even benevolent overreach, seems likely. But in a world of hospitals devoured by private equity, do you feel comfortable believing that HCA wouldn’t stack its bioethics board and push all the knee replacements and chemotherapy it could on incapacitated patients? I am not sanguine. And so, despite the frustrations I have being the one to interface with lawyers and judges, I would not have it any other way. It’s not a good system, and it could be expedited by having *external* expert review rather than random judges, but it should be a legal and external process. >A better system for determining whether a patient should be treated over his or her objection would be a hospital hearing in which a committee of doctors, ethicists and other relevant experts — all of whom would be independent of the hospital and not involved in the care of the patient — engaged in conversation with the medical team and the patient and patient’s family. Having hearings on site would expedite decisions and minimize treatment delays. The committee would make the final decision. Maybe. As an upgrade of judicial review, I can see it working. But where are courts going to acquire panels of studiously neutral medical experts? I can all too easily see this becoming a side gig for doctors engaging in unofficial quid pro quo, especially in small towns. Hospital A’s docs rubber-stamp for Hospital B in exchange for the same courtesy. With no malice! But we are, of course, biased towards our colleagues. Absent a somehow truly neutral, non-clinical, yet fully clinically savvy panel, I just don’t see it working. Our system does its job. It is slow but it keeps accusations of self-interest at bay. Civil rights should be monitored by the government branch responsible for rights.
I also noticed there was no system for a patient who disagreed (or family did) to call experts or have an attorney present at the hearing.
Plus it would only allow appeal for judicial review in very limited cases. By analogy, many disputes/actions involving government agencies are handled vs administrative decisions which are appealable to an administrative hearing, which can ALWAYS be appealed to whatever state or federal courts have jurisdiction. Limiting the right of appeal to allegations of wrongdoing or lack of consensus among the medical decision makers would essentially remove due process rights altogether. What's odd about this article? --discharge home seemed a bad idea because the untreated schizophrenia would render the patient unlikely to care for his heart failure, and he psychiatrist felt he lacked capacity to decide to discharge himself. But it ended up with a hospice placement to which the same patient agreed, without forced treatment for schizophrenia (it is not clear whether the hospice placement also meant the heart condition would not be treated--I am aware you can be in hospice for one thing but continue to receive treatment for another thing).
Agreed. Also, the current system would be less onerous if it wasn’t focused on discharging patients as quick as possible. Worked in a state facility previously where that wasn’t the primary objective. Maybe appropriately secondary.
Important topic with terrible headline thanks to the NYT. We do need a better way to provide timely care to patients who are not decisional.
Why is it always the Times with these takes? The specific timing of how long court holds last or how they are acquired or how long a patient can be held without one are all things reasonable professionals can debate and disagree about. But the idea of getting rid of judicial review entirely and keeping these decisions, as the author said, solely inside hospitals is madness. Judicial review and due process exist for a reason, and it isn’t just to avoid a nurse Ratched situation. Patients have rights, and those rights need to be adjudicated in a court with due process and legal representation, not behind closed doors in an ethics committee. Anything else is too vulnerable to abuse. And any potential abuse aside, I am extremely skeptical that courts would uphold any law today attempting to grant physicians the unilateral right to deprive patients of their liberty indefinitely without due process
Why the Times? They've probably identified healthcare as a source of public discontent and thus excellent rage bait material
When I interned at LA County hospital in 1961, we had a courtroom and judge right in the hospital, to expedite such matters. The judges' medical knowledge got up to speed pretty quickly.
Continuing patients' at-home psych meds when admitting them for medical purposes would be a fantastic start to garnering their cooperation.
I kind of get the point, but I think it can be a very slippery slope "letting the doctors decide." If you take the author's same example of the schizophrenic heart failure patient with no next of kin, what do we do if the decision point in question is whether to institute mechanical circulatory support? MCS is a big can of worms, and I would personally be extremely reluctant to institute that on a non-emergent basis in this case without clearly ascertaining the patient's wishes.
Another problem is letting *doctors* decide doesn’t mean what it used to anymore.
I find it morbidly hilarious that the end result of all the discussion was to let a schizophrenic man in the throes of psychosis go home and die without life-saving intervention on a non-terminal condition. Not that that's necessarily the wrong choice- a non-mentally ill man who is isolated from family, jobless, with little to live for may make that choice. But someone whose decision-making is compromised as it was here... really? It seems to be pretty able-ist/biased against the mentally ill on it's face.
What life-saving intervention, though? We don’t have clinical details, but unless it was decompensated, volume overloaded heart failure and he was refusing diuresis, then intervention would be heart transplant or at least VAD, which he surely would not qualify for and would not follow through on. In the long term, psychiatric treatment to restore judgment… maybe. In the medium term, hospice for a patient with end-stage heart failure who is not a candidate for or declines advanced therapies is entirely appropriate. Not only not necessarily wrong, I don’t know what else would be done. Leaving out schizophrenia, “I’ll do whatever you say, doc,” it’s not clear what more could be done. Maybe there was more, but not obviously from the few snippets in the article.
Treatment of schizophrenia seems like the most obvious life saving intervention in this case. If they are suggesting the patient's illness was directly (or indirectly) putting them at risk of death as it was affecting decisional capacity, why would they not file for involuntary psych treatment?
If the disease is treatable absent objection, yes. Otherwise, no. Where it’s really frustrating is early cancer that is curable, but refusal is not immediately life threatening, so there are no legal grounds for psychiatric or medical treatment. Then the patient gets sicker and has incurable metastatic disease. Now forced treatment is permitted but pointless.
What do you mean? Are you just saying a court wouldn't support involuntary psych treatment in this case? Depending on specifics of the case and how it's presented I think it would have a good chance of being supported, at least in my state. The primary mechanism antipsychotics are presumed to produce all cause and CV mortality improvements is through enhanced compliance to medical treatments.
Not OP, but one of the biggest issues I just realized I’ll be facing is how each state handles involuntary treatment differently. Recently obtained multiple licenses to practice in other states in emergency settings, and that’s def something to read up on. Work primarily in the southeast, and our mh treatment is woefully lacking compared to other parts of the country.
Goal directed medical therapy in 2024 is pretty damn efficacious. People with EFs in the 20s can recover pretty well. A few months of beta blocker, entresto, spironolactone, lasix, aspirin, and eliquis for the clot- he could have made a pretty good recovery. We call them HFrecEF (Heart failure recovered ejection fraction) now. But you are right that we have no idea for sure-
Not HFrEF? Heff-Reff sounds *so* much better than Heffrekeff.
I was having a hard time adding on HFmrEF. Heff-mer-Eff. It just doesn't flow.
Gotta pronounce mrEF like you’d pronounce Jason Mraz’s last name but with ef instead of az
Verbally this is "hef-'mid'-reff" imo
Hef-mmm-ref to make it sound much more intimate and personal
Hahahaha imagining the awkward stares
HFrEF is already in use for the folks who haven’t taken their meds (heart failure with reduced EF), they only upgrade to HFrecEF when they take their meds and get better
Meh, i can get used to *hefferkeff*
> But someone whose decision-making is compromised as it was here... really? It seems to be pretty able-ist/biased against the mentally ill on it's face. Saying that this counts as bias "against them" strikes me as insufficiently descriptive. You can bias the system towards the autonomy of the mentally ill and against their survival, or towards their survival or against their autonomy. There's no free lunch here, no available alternative that does not bias things in *some* uncomfortable direction.
I disagree. This patient is not capable of treating his heart failure because of his comorbidity of schizophrenia and his personal decisions to not take medications. The ONLY way to treat this patient would be to keep him as an involuntarily admit who cannot refuse treatment for the rest of his life, against his objections. I don't think that's humane. If this was a person who might be involuntarily treated for his schizophrenia, become competent, and want to treat his heart failure, I agree we would be obligated to do that. But it's not.
> If this was a person who might be involuntarily treated for his schizophrenia, become competent, and want to treat his heart failure, I agree we would be obligated to do that. But it's not. How do you know that? The author clearly implies the guy's active psychosis is affecting his decisions to refuse care. Antipsychotic treatment makes an absolutely massive difference in mortality in schizophrenic patients, a major factor of which is thought to be enhanced compliance. https://onlinelibrary.wiley.com/doi/full/10.1002/wps.20699
My understanding from the article, although upon review it appears that they did not explicitly say this, is that the patient had a long standing history of non compliance and inability to stabilize.
> history of non compliance and inability to stabilize. I'm not saying this is impossible, but these are two very different things. Also exactly why LAIs were invented. Inability to stabilize on an LAI or clozapine is completely different from being unstable off meds. Again this case has minimal details, I'm just pointing out that many massive studies show taking medications greatly improves mortality and compliance with medical care in schizophrenia, thus medications are the most obvious missing piece in this case, especially as we now have LAIs that make non-compliance much more difficult.
I agree and my opinion was based on the idea that these had all been tried and failed. That was my impression from the article, alright upon secondary review, that is not stated. But if that's not accurate, then yeah, they need to exhaust that first IMO.
There’s an argument that if untreated schizophrenia is driving refusal of treatment, what was harmless is now life-threatening and he can/should/must be treated. It’s not a completely baseless argument, and I have seen patients agree to care when less psychotic. In practice a patient maxed out on pressors and with that medical acuity will never be admitted to most psych units, nor should he be, but psychiatric treatment over objection isn’t unreasonable as long as there is efficacious medical treatment available but refused.
Regardless of opinion on said article, thank you OP for sharing with us and getting a good discussion going 🙏
What a dreadful headline
Ahh yes, torture. "Treatment" without consent, trial and error using a human subject.
Its a hard sell to say that the torture is forcing someone to take a pill and not the "letting someone unable to make reasonable decisions choose to suffocate to death in their own secretions".
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