Navigating the Minefield: Managing Refusal of Medical Care in Older Adults with Chronic Symptoms of Mental Illness

Abstract

The purpose of this case series is to illustrate the complexity of considerations across health (physical and mental), ethical, human rights and practical domains when an older adult with chronic symptoms of mental illness refuses treatment for a serious medical comorbidity. A broad understanding of these considerations may assist health care professionals in navigating this challenging but common aspect of clinical practice. Case Presentation: Three detailed case reports are described. Participants were older adults with an acute presentation of a chronic mental illness, admitted to a specialized older persons mental health inpatient unit (OPMHU) in an Australian metropolitan hospital. Significant comorbid medical issues were detected or arose during the admission and the patient refused the recommended medical intervention. Data extracted from patients' medical records were analyzed and synthesized into detailed case reports using descriptive techniques. Each patient was assessed as lacking capacity for healthcare and treatment consent and did not have relatives or friends to assist with supported decision-making. Multifaceted aspects of decision-making and management are highlighted. Conclusion:There are multiple complex issues to consider when an older adult with chronic symptoms of mental illness refuses treatment for serious comorbid medical conditions. In addition to optimizing management of the underlying mental illness (which may be impairing capacity to make healthcare decisions), clinicians should adopt a role of advocacy for their patients in considering the potential impact of ageism and stigma on management plans and inequities in physical healthcare. Consultation with specialist medical teams should incorporate multifaceted considerations such as potentially inappropriate treatment and optimum setting of care. Equally important is reflective practice; considering whether treatment decisions may infringe upon human rights or cause trauma.

Age discrimination perceived by hospitalized older adult patients in Iran: A qualitative study

“…These led them to treat older adult patients differently and consider caring for them pointless and time-consuming. Our findings were in line with other studies that reported misperceptions by healthcare team about old age and the inherent nature of certain symptoms with old age, 26 treating an older adult patient is pointless, 27 and they are not worthy of care. 28 In another study, Heydari and colleagues stated that there are misconceptions about older people and that they are perceived incapable of adapting to new situations, ineducable, impatient, irritable, and bad-tempered.…”

The perspectives of hospital doctors about end‐of‐life care in people with mental illness: an observational pilot study

“…While the evaluation of clinician knowledge about capacity assessment and related legal frameworks is beyond the scope of the current study, they are relevant practical aspects of health care decision-making, which may also be affected by mentalist attitudes. 11 Addressing doctors' stigma regarding PLWMI is a core clinical implication of this study. According to Knaak and Patten, 32 targeting the roots of stigma in health care through evidence-based initiatives is a fundamental starting point.…”

“…10 Mentalism is a major barrier to quality treatment and care. 9,11 Stigmatisation of people with mental illness acts as a barrier to physical health care across all areas of the health care system 7,9 and the poorer health outcomes of PLWMI continue throughout the lifespan, including at the end of life. 5,12 These negative end-of-life outcomes for PLWMI include poorer symptom management, such as pain management, 13 less engagement in advance care planning 14 and significantly lower likelihood of accessing specialist care, including palliative care.…”

“…Such discrimination based on the presence of mental illness has been articulated as ‘mentalism’ 10 . Mentalism is a major barrier to quality treatment and care 9,11 …”

Decision-Making Capacity to Refuse Treatment at the End of Life: The Need for Recognizing Real-World Practices

“…We will focus on one paper as an example. When we searched the database using the above keywords, we found four categories of papers: (1) written mainly from the perspective of ethicists or philosophers [ 1 , 2 , 3 ]; (2) written mainly from a clinical perspective [ 4 , 5 , 6 , 7 , 8 ]; (3) written mainly from the perspectives of other fields such as law [ 9 , 10 , 11 ]; (4) written mainly by interdisciplinary expert authors such as clinicians and ethicists [ 12 , 13 , 14 , 15 , 16 ]. All categories have merits and demerits.…”