An Elderly Woman Who Refuses Treatment

by Madhav Raje | April 16, 2012 12:24 PM EDT

Hi, I'm a practicing Psychiatrist & psychotherapist from India.
Case of Mrs. E seems interesting, though information is not adequate, it seems that she is suffering from Dementia with depressive features. However she needs full medical evaluation to arrive at full clinical diagnosis. She may accept to get evaluated. Clinician's rapport would do needful.
Secondly, she is not denying for treatment. It seems that she needs to talk her concern out, that she fears that medicine might kill her due to fragility as a result of ageing. If clinician can persuade her with brief psycho therapy, establish good working rapport, she might give consent willingly for treatment. If therapist add little Gestalt therapy along with cognitive therapy if needed, her consent to treatment wound not be a difficult task.
If she satisfies criteria of competency then this psychotherapy is inevitable. But suppose she does not satisfies all 4 criteria then she can be treated under consent obtained from authentic career or legally permissible person.
If all these avenues fail then only covert medication can be resorted at. Documentation of all record becomes mandatory in case of covert medication. I support covert medication fully under all documentary formalities in some of the rare cases as a last resort. I value life more than Autonomy or person's right to deny treatment, etc.
Dr. Madhav Raje, 16.04.12

by Hyman Beshansky | April 13, 2012 9:57 PM EDT

Does the patient understand the consequences of refusing treatment? People can refuse therapy and medication but if they understand the consequences and that the person is refusing based on his/her values and not the clinical depression, it would be difficult in a nonthreatening situation i.e suicidal or homicidal thoughts, plan and/or intent, to start involuntary treatment. Is this patient meeting her biological needs ie. sleeping, eating that does not put her at medical risk for dehydration. Does she understand that eating and sleeping "less than usual"is a sign of depression? What would her response be if an MD told her that she was at medical risk and "failure to thrive"?

by Dheeraj Raina | April 13, 2012 6:26 AM EDT

This vignette is too bare-bones to have a meaningful discussion about ethical issues involved. For example, issues to be considered in this case begin with - what is the underlying diagnosis resulting in the presenting symptoms? The above presentation could be seen in depression, but could also be seen in progressive dementia, or in an infectious process (e.g., UTI) in a person with dementia, or thyroid dysfunction, and so on. Even if it is 'just' depression, in this vignette, Mrs. E is not refusing treatment for depression - she is just refusing antidepressant medications. We don't know if there has been a frank and open discussion about other treatment alternatives and their relative potential advantages and disadvantages. Even if this is depression, does she have a h/o recurrent depression? Historically, how does her depression behave? When it progresses, does she often become suicidal? Does she often stop behaving the way she is now? Too many unanswered questions to have a meaningful discussion about ethics

by Chris Verster | April 13, 2012 4:00 AM EDT

Obviously there are legal issues to consider - e.g. slipping the liquid fluoxetine into her food/drink could have legal consequences. But this matter also speaks to paternalism - when can a benevolent health care-worker decide for a patient?

by Ron Fletcher | April 12, 2012 7:26 PM EDT

I always find it disturbing when any decision is made by a patient (particularly if they're older) which differs from the doctors, their competence is brought into question. There was no question of Mrs E's competence before this incident.
I'd like to see Mrs E's doctor sitting down and having a nice long discussion with her to find out what she wants out of life at this time.
Even though the best "medical decision"for Mrs E may be to go on antidepressants, Mrs E is more than a clinical case study; she is a woman who has 80 years of life experience and a life plan of her own. Perhaps, Mrs E has made a logical decision that fits in with her plan for her life and perhaps we should respect that.
Whatever her situation or diagnosis, our first responsibility should be to ascertain what she wants and see if we can accommodate that. "I'm 80 years old and I'm not about to start taking medications now. That would kill me!" sounds like the sort of response I'd expect from a lot of older people - do we deem all older people incompetent?
Try reading the description above replacing "Mrs E" with "I" and assessing it from a human as well as clinical viewpoint; perhaps your decisions will be different.

Ron Fletcher (RN1 & Mental Health Nurse)