End-of-Life Decision-Making Capacity in Older People With Serious Mental Illness.

Carla Kotzé,René Ehlers,Johannes Lodewikus Roos

doi:10.3389/fpsyt.2021.752897

Abstract

Background: The study's main aim was to assess the end-of-life decision-making capacity and health-related values of older people with serious mental illness.Methods: A cross-sectional, observational study, was done at Weskoppies Psychiatric Hospital, Gauteng Province, South Africa that included 100 adults older than 60 years of age and diagnosed with serious mental illness. The Mini-Cog and a semi-structured clinical assessment of end-of-life decision-making capacity was done before a standardized interview, Assessment of Capacity to Consent to Treatment, was administered. This standardized instrument uses a hypothetical vignette to assess decision-making capacity and explores healthcare-related values.Results: The Assessment of Capacity to Consent to Treatment scores correlated (p < 0.001) with the outcomes of the semi-structured decision-making capacity evaluation. Significant correlations with impaired decision-making capacity included: lower scores on the Mini-Cog (p < 0.001); a duration of serious mental illness of 30–39 years (p = 0025); having a diagnosis of schizophrenia spectrum disorders (p = 0.0007); and being admitted involuntarily (p < 0.0001). A main finding was that 65% of participants had decision-making capacity for end-of-life decisions, were able to express their values and engage in advance care discussions.Discussion and Conclusion: Healthcare providers have a duty to initiate advance care discussions, optimize decision-making capacity, and protect autonomous decision-making. Many older patients with serious mental illness can engage in end-of-life discussions and can make autonomous decisions about preferred end-of-life care. Chronological age or diagnostic categories should never be used as reasons for discrimination, and older people with serious mental illness should receive end-of-life care in keeping with their preferences and values.

Highlights

End-of-life care is associated with important decisions that can give rise to many ethical dilemmas and discussions [1]
It should be ensured that chronological age alone is never a reason for discrimination and that older populations with serious mental illness (SMI) retain the right to participate in healthcare decisions
This study adds to the literature about end-of-life care in the older population with SMI, with an emphasis on the individual and contextual nature of decision-making capacity (DMC) and the importance of the healthcarerelated values of older patients with SMI

Summary

Introduction

End-of-life care is associated with important decisions that can give rise to many ethical dilemmas and discussions [1]. Disparities between the health and health care for patients with schizophrenia and those without a diagnosis of a mental illness have been reported in the literature [2]. This raises questions about the end-of-life care needs of this vulnerable population when they develop progressive disease with an expected survival of months or less [3, 4]. Healthcare practitioners may neglect to discuss end-of-life care with patients out of a fear to provoke negative reactions or erroneous assumptions about how mental illness impairs healthcare decision making [5]. The study’s main aim was to assess the end-of-life decision-making capacity and health-related values of older people with serious mental illness

Objectives

Methods

Results

Discussion

Conclusion