End-of-life decision-making capacity in an elderly patient with schizophrenia and terminal cancer.

Carla Kotze,Johannes L Roos

doi:10.4102/safp.v62i1.5111

Abstract

Medical practitioners are confronted daily with decisions about patients’ capacity to consent to interventions. To address some of the pertinent issues with these assessments, the end-of-life decision-making capacity of a 72-year-old female with treatment-resistant schizophrenia and terminal cancer is discussed, as are the role of the treating clinician and the importance of health-related values. There is a recommendation that the focus of these assessments can rather be on practical outcomes, especially when capacity issues arise. This implies that the decision-making capacity of the patient is only practically important when the treatment team is willing to proceed against the patient’s wishes. This shifts the focus from a potentially difficult assessment to the simpler question of whether the patient’s capacity will change the treatment approach. Clinicians should attend to any possible underlying issues, instead of focusing strictly on capacity. Compared to the general populations people with serious mental illness (SMI) have higher rates of physical illness and die at a younger age, but they do not commonly access palliative care services. Conversations about end-of-life care can occur without fear that a person’s psychiatric symptoms or related vulnerabilities will undermine the process. More research about palliative care and advance care planning for people with SMI is needed. This is even more urgent in light of the coronavirus disease-2019 (COVID-19) pandemic, and South African health services should consider recommendations that advanced care planning should be routinely implemented. These recommendations should not only focus on the general population and should include patients with SMI.

Highlights

Medical practitioners are confronted on a daily basis with decisions about patients’ capacity to consent to interventions as required by law and medical ethics
Most medical practitioners will use their own subjective judgement and clinical experience in situations where capacity has to be assessed, but all such assessments should be done in the context of a thorough clinical evaluation.[2]
The ultimate goal of determining capacity is to maintain a proper balance between respect for patient autonomy and protecting those who lack capacity from making harmful decisions

Summary

Introduction

Medical practitioners are confronted on a daily basis with decisions about patients’ capacity to consent to interventions as required by law and medical ethics. The aim should be to treat pain, manage symptoms, relieve suffering, provide psychosocial and spiritual support, and not to prolong or hasten death.[13] Patients should be encouraged to take ownership of their illness and it is good clinical practice for both the clinician and patient to participate in the planning and choosing for the road ahead.[14] stigma towards patients with SMI is prevalent and it often manifests in lower quality end-of-life care and the misattribution of medical symptoms to psychiatric illness.[15] This case highlights the differences in opinion about decisionmaking capacity, but the end-of-life care and proposed treatment were not an issue here. These recommendations should focus on the general population and should include patients with SMI

Ethical consideration

Data availability statement