Schizophrenia Spectrum Disorders

The case study below describes Charlie, a patient who was successfully able to discontinue medication for schizophrenia before having a relapse. Read the case study and write a 250-500 word essay in which you:

1. Summarize and reflect on this case study
2. Discuss the ethical issues involved in "forcing" treatment in cases of serious mental illness. Your discussion should include at least 2 ethical issues presented in this case study (e.g., the balance between personal rights vs the rights of others/greater good, what is required to determine whether someone is capable of consenting to or refusing treatment, the balance between a family's legal right to make a treatment decision vs appropriate medical management, or any another ethical issue you see in this case study).
3. Discuss the advantages and disadvantages of a "psychiatric advanced directive" in Charlie's situation and in similar cases.

You will be graded according to the attached rubric.

Case Study

Charlie is a 55-year-old White male with a history of schizophrenia who has been stable and functioning for over a decade. Due to his significant personal concerns about possible adverse effects of antipsychotic medications, Charlie discontinued pharmacological treatment in close collaboration with his psychiatrist two years ago. Until recently, he was able to function well without medications and reported feeling much healthier with regard to his phsyical despite some worsening of other psychiatric symptoms. In particular, he was able to lose a significant amount of weight and no longer suffered from the lipid and blood sugar abnormalities that he experienced while on antipsychotic medications.

Charlie continued to meet regularly with his psychiatrist throughout this period and repeatedly expressed his desire to avoid all medication treatment in the future. With the support of his wife, Reina, and his adult daughter, Laura, he and his psychiatrist developed a plan to support a medication-free lifestyle and treatment approach. This plan, which involved bi-weekly therapy sessions and regular involvement with a community support group, appeared effective at managing his symptoms. However, Charlie began experiencing a resurgence of his schizophrenia symptoms, in particular paranoid delusions, approximately 2 weeks ago. He was involuntarily hospitalized after he attacked Laura, accusing her of being an imposter. Out of respect for his desire to avoid medications, his inpatient treatment care team tried to stablizie him and further manage his care without medications. However, 2 weeks after his initial hospitalization, Charlie remains actively psychotic and continues to pose a significant risk to others.

Laura and his inpatient treatment team are interested in discussing whether it would be possible and warranted to reintegrate him into his family and community with the help of a short, stabilizing course of antipsychotic medication. Reina, however, fully supports Charlie's decision to continue refusing medication and in a family meeting, she reminded Laura and the treatment team that while Charlie lacks the capacity to make decisions for himself in his current state, he clearly and repeatedly expressed his wishes when he was well.

Because Charlie was admitted involuntarily, Reina is legally responsible for making medical decisions for him, and she repeatedly asserts that she will not authorize treatment, including antipsychotic medications, to which she does not think Charlie would consent if he were able. Reina is also aware, however, that her decision not to allow medication as part of Charlie's treatment is making his symptoms severe and exacerbating the risk he poses to himself and others on the adult inpatient psychiatric unit. Specifically, Charlie frequently acts out in response to his delusions by yelling at staff, refusing to eat because he fears the food is poisoned, and threatening other patients. He freqeuntly disrupts group therapy sessions with his outbursts and despite doing all they can to help him, his treatment team, especially his 1:1 nurse Sheni, is becoming increasingly frustrated.

With Charlie's behavior continuing to escalate, Sheni recently approached the attending psychiatrist, Dr. Naobi, with her concerns, saying, "I don't think it's fair to Charlie or the other patients on the unit for us not to manage his symptoms effectively and appropriately. How can we treat him with compassion and respect if we don't treat the symptoms from which he is suffering so acutely and for which we have an evidence-based, accessible solution? It's just not good care -- and maybe even malpractice if you ask me -- for us to continue letting his symptoms go untreated. It's also not fair the other patients aren't getting the care they deserve, because we have to spend so much time managing Charlie's symptoms."

Dr. Naobi agreed with Sheni's observations and suggested that another family meeting would be worthwhile to try to address these concerns. In that meeting, Sheni described in detail the severity and frequency of Charlie's symptoms and behaviors and how they were affecting her, her colleagues, and the other patients. After hearing Sheni speak, Laura confronted her mother, insisting that she authorize medications, yet Reina remained adamant in her refusal, saying, "Charlie has told me AND this entire team time and time again what he wants. We are his best advocates and even if I'm the only one left, I will advocate for his wishes to be respected. I know this is hard on everyone, and I regret that. It pains me to see him like this, but I must follow his wishes." Dr. Naobi further expressed concerns that while it was difficult on everyone, Charlie, too, was suffering immensely. He indicated that allowing Charlie to suffer by continuing along an ineffective and worsening course was clinically and ethically inappropriate stating, "We've tried this for 2 weeks, and it's just not working. From a clinical standpoint, many would regard our current approach as medical mismanagement -- as substandard care at best and overtly harmful at worst." Upon hearing this, Reina became very angry and replied, "You don't know Charlie like I do. I remember how much he suffered due to those medications. I watched him suffer then, too. His symptoms were controlled, but at what cost? The medications made him fat and left him feeling sluggish all the time. My husband and I talked about this often and for a long time before we decided that he wasn't going to take the medications anymore. It wasn't a decision we made lightly, and I am not going to betray his trust in me because managing his illness is inconvenient for you."

Despite feeling very conflicted, Dr. Naobi responds calmly, saying "I also believe that Charlie's wishes deserve respect. Let's end this meeting on that common ground and take another day to think this over together." Dr. Naobi knows that Reina has legal authority to make treatment decisions for Charlie, but he suspects that the scope of her influence has now entered the realm of medical management, which ought to be the clinician's prerogative. Knowing that his duty is ultimately to his patient, he wonders how best to communicate this concern to Reina in a way that will help and not hinder Charlie's care. He also wonders about how best to support and act in solidarity with Sheni and his other colleagues and in the best interest of the other patients on the unit