Older Persons Mental Health Service, Jara Unit, Concord Centre for Mental Health, Concord Repatriation General Hospital, Concord, NSW, Australia.
Specialty of Psychiatry, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.
Clin Interv Aging. 2021 Jul 12;16:1315-1325. doi: 10.2147/CIA.S311773. eCollection 2021.
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.
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.
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.
本病例系列旨在说明当患有慢性精神疾病的老年患者拒绝治疗严重的合并医学病症时，在健康（身体和心理）、伦理、人权和实际等多个领域需要考虑的问题的复杂性。广泛了解这些问题有助于医疗保健专业人员应对临床实践中这一具有挑战性但又常见的方面。
描述了三个详细的病例报告。参与者是患有慢性精神疾病急性发作的老年患者，他们被收入澳大利亚大都市医院专门的老年精神健康住院病房（OPMHU）。在住院期间发现或出现了严重的合并医学问题，而患者拒绝接受建议的医疗干预。从患者的病历中提取的数据，采用描述性技术分析并综合为详细的病例报告。每位患者均被评估为缺乏医疗保健和治疗同意的能力，且没有亲属或朋友协助做出支持性决策。突出了决策和管理的多方面问题。
当患有慢性精神疾病症状的老年患者拒绝治疗严重的合并医学病症时，需要考虑多个复杂问题。除了优化对潜在精神疾病的管理（这可能会损害做出医疗决策的能力）之外，临床医生还应在考虑年龄歧视和污名对管理计划的潜在影响以及身体保健方面的不平等时，为其患者扮演倡导的角色。与专科医疗团队的协商应纳入多方面的考虑因素，例如潜在不适当的治疗和最佳护理环境。同样重要的是反思实践，考虑治疗决策是否侵犯人权或造成创伤。
