“You Aren’t Going to Cut On Me!” Urgent Medical Decisions for Patients With Schizophrenia

Abstract

Abstract Background Decision-making capacity of patients with schizophrenia remains a highly debated subject, both in terms of understanding the effects of the illness, and in the challenges presented by clinical scenarios. Clinicians are frequently asked to evaluate decision-making capacity in patients with schizophrenia admitted to medical/surgical services, and these cases pose many clinical and ethical challenges. Objective/Method Two cases are presented of individuals with schizophrenia that refused emergent surgical care. Results Evaluation by the psychiatry consultation-liaison service deemed both patients to lack decision-making capacity, yet, in light of patient- and case-specific factors, surgery was performed in only one case. Discussion Acute medical conditions may complicate the evaluation of decision-making capacity in patients diagnosed with schizophrenia. Frequently, the psychiatrist has additional time pressure for their assessment, particularly when a patient presents with an acute or unstable condition requiring emergent intervention, such as surgery. Additionally, irreversible consequences due to refusal of intervention provokes provider discomfort, particularly given the opposing tension to respecting patient autonomy. In contrast, surgical providers may be unwilling to surgically intervene on patients deemed to lack capacity, as the patient may have a lower chance of recovery. Either extreme poses ethical dilemmas: forcing invasive treatment on a patient, or withholding medical interventions from certain psychiatric patients. Conclusion In cases of great complexity, decision making capacity assessments should be guided by a sliding scale, and when evaluating for the appropriateness of treatment in patients lacking capacity, clinicians should utilize the core ethical values to guide their decisions.