When Self Harm Becomes Terminal : The Ethics Of Decision-Making In Self Induced Terminal Illness

Key Message: Treatment-refractory psychiatric patients present complex ethical dilemmas for medical teams. This case highlights the importance of interdisciplinary collaboration for patients with treatment-resistant mental health conditions.

Abstract:

Background: This case addresses the process of determining hospice eligibility when a terminal diagnosis stems from a psychiatric condition.

Case Description: A 44-year-old man with borderline personality disorder, impulse control disorder, and self-injurious behaviors presented with complications from repeated self-inflicted abdominal wounds. Despite extensive interventions over the course of a decade the patients condition including his psychiatric disease failed to improve. He was admitted with chronic enterocutaneous fistulas with high ostomy output, acute kidney injury, and severe, chronic malnutrition. The patient lacked decision-making capacity but expressed consistent and authentic preferences for a regular diet and adequate pain control, even if this would hasten his dying process. He refused parenteral nutrition and would frequently remove lines and other devices. The patient’s advanced directive from a decade prior stated that if he were dying, he prioritized pain relief. His healthcare surrogate was unable to serve as his proxy due to medical issues. His brother was assigned as healthcare proxy and agreed that transition to comfort measures would be aligned with patient’s values and maintain his dignity.

Discussion: An interdisciplinary approach involving surgical nutrition, psychiatry, palliative and bioethics determined that the patient had terminal intestinal failure secondary to treatment-refractory psychiatric conditions. After review of the patient’s advance directive and conversations with the healthcare proxy, care focus was shifted to comfort measures. This case illustrates the importance of multidisciplinary discussion, review of advance directives, involvement of healthcare proxies and in-depth ethical analysis given the complex intersections of non-beneficial treatments and patient autonomy.

Conclusion: Treatment-refractory psychiatric patients present complex ethical dilemmas for medical teams. Key takeaways include the need for interdisciplinary agreement when establishing terminal diagnoses secondary to psychiatric conditions and the importance of comprehensive shared decision making involving all stakeholders, as well as critical evaluation of autonomous preferences, substituted judgement and best interest standard.

References: Trachsel, M., Irwin, S. A., Biller-Andorno, N., Hoff, P., & Riese, F. (2016). Palliative psychiatry for severe persistent mental illness as a new approach to psychiatry? Definition, scope, benefits, and risks. BMC Psychiatry, 16, 260. https://doi.org/10.1186/s12888-016-0970-y

Puchalski, C., Vitillo, R., Hull, S. K., & Reller, N. (2013). Management of end-of-life care and of difficult behaviors associated with borderline personality disorder. Journal of Pain and Symptom Management, 45(4), 777-789. https://doi.org/10.1016/j.jpainsymman.2012.05.014