This case highlights clinical dilemmas faced by physicians when treating patients with conditions for which there are limited or no FDA-approved treatment options. First, it raises questions about when it is appropriate to prescribe medications for "off-label" indications and what might be the ethical and legal implications of doing so. It also prompts us to consider why pharmaceutical companies might or might not pursue FDA approval for new indications when a drug has already been approved for use in another condition. Finally, this case demonstrates the importance of employing shared decision making when discussing complex clinical decisions and how such techniques might have led to different outcomes and better understanding between Dr. Shannin, Maxine, and Heather.
CaseHeather brings her 89-year-old mother, Maxine, to the office of her psychiatrist, Dr. Shannin, for an evaluation. Maxine lives with Heather's family, and though she has been diagnosed with dementia, she still sees Dr. Shannin in his office by herself while Heather waits for her in his office lobby. During her last visit with Dr. Shannin three months ago, Maxine reported that whenever she got confused, she began to think that the people around her were going to harm her. Heather also expressed concerns about Maxine's confusion and paranoia, since Maxine would typically respond to those feelings by acting out as if she were being threatened. Maxine was unable to remember these outbursts, but she did remember feeling agitated and did note that Heather seemed very upset when she felt that way. At that time, Dr. Shannin suggested that Maxine try an atypical antipsychotic, olanzapine, to help control her agitation and paranoia. He explained the risks and benefits in detail and also explained that while he'd had good results with several patients with this medication in the past, managing confusion, agitation, and paranoia was not what this medication is really for. Maxine felt confident that Dr. Shannin had used this medication to manage these symptoms for his other patients, however, and so she agreed to begin taking olanzapine, which has managed her symptoms well for the last three months.Maxine's dementia has progressed significantly since her last visit with Dr. Shannin, and she is having a particularly bad day today: she doesn't recognize her longtime physician
