Psychiatrist

Volume 39, Number

A fresh view of goals on care- Continued

This legal document outlines a patient’s treatment preferences in the setting of a psychiatric health crisis7, laying the groundwork for an improved therapeutic alliance between patient and provider, evidenced by improved continuity of care and treatment adherence.8 While completing this PAD, it will be important to identify a power of attorney for MG, as he previously has struggled maintaining supports in his life. Completion of a PAD will allow MG’s providers to recognize warning signs of impending destabilization, preferred medications, preference for inpatient versus outpatient care, desire for certain types of therapy, and who he would like included as part of his treatment team.7 The hope is that early intervention can begin once warning signs develop and ideally prevent inpatient hospitalizations, a measurable sign of progress for MG.

“Psychiatric patients always have someone telling them what they’re supposed to do. In my experience, I discovered that it was much more effective to be asked what I like, and how [healthcare providers] could help me get there.” –E. Saks

Once emergency care interventions are established, the focus then shifts to addressing more chronic aspects of MG’s illness and care. Identifying which psychiatric symptoms are most distressing to him and what medication side effects are intolerable are both crucial in guiding MG’s long-term care. In many patients with SMI, there is a debate of whether certain pharmacologic treatments may be deemed futile after a certain point in their care.9

While creating a medication regimen together, providers may employ non-maleficence by avoiding the iatrogenic effects associated with certain treatments that have unclear efficacy.9 Other important considerations include activities of daily living (ADLs) that MG would like to maintain, life goals and aspirations (about school, career, family life, etc.) and what quality of life means to him. Paternalistic views are prevalent in psychiatry, and what providers may deem as appropriate treatment goals may not align with the patient’s desires. This once again highlights that patient autonomy should be central to this care model. It has been shown that when patients are a part of the decision-making process, they are more likely to adhere to treatment.10 By establishing what is truly important to MG, a collaborative approach to his care will be maintained to better align with autonomy, furthering treatment success, while simultaneously avoiding further harm.

Spring 2023

Volume 39, Number 1

A fresh view on goals of care- Continued

“I’d managed to stay out of the hospital for two years…there is no denying that my [treatment team] has been the determining factor in all of that.” –E. Saks

To address MG’s medical co-morbidities, it must first be emphasized that patients with SMI die approximately 15-25 years earlier than those without SMI.4 In the case of Elyn Saks, who suffered from headaches and memory impairments, “a completely predictable disaster happened: the ER discovered that [she] had a psychiatric history. That was the end of any further diagnostic work.”1 Regardless of a significant subarachnoid hemorrhage, Saks was judged based on her mental illness. On a larger scale, palliative psychiatry needs to include education to all healthcare providers, to provide a better interdisciplinary approach to care for those with SMI and to help reduce further stigmatization. On a smaller scale, with specific regard to MG’s medical conditions, assessing health literacy of tobacco use, CAD, and HF will aid in identifying individual goals of care for him. Although providers encourage smoking cessation or specific diets and exercise routines necessary for CAD management, this may not be an attainable goal for MG. Thus, by respecting his autonomy, a more realistic approach may include motivational interviewing, prescribing nicotine replacements, and encouraging preventative screening for lung cancer. MG will also require assistance establishing care with an appropriate cardiologist for management of CAD and HF. An emphasis on harm reduction over full remission may be more appropriate in this case. With these strategies in place, MG may have success managing his medical comorbidities and his providers will employ beneficence and non-maleficence to the degree that aligns with his goals.

“I had attainable goals, a sense of productivity and purpose, and tangible results against which I could measure my progress.”

After implementing the palliative framework listed above, health outcomes can be measured for progress and success. Regarding MG’s treatment, success may result in fewer inpatient admissions and more engagement with partial hospitalization programs. In terms of medication adherence, success may include a non-distressing chronic baseline delusion, which prevents him from reaching a dose of anti-psychotic that leaves him lethargic. It may include a monthly long-acting injectable, to reduce the pill burden of twice daily dosing. Regarding quality of life, success may look like more social engagement and participation in support groups. It may include therapy to better manage behavioral changes, resulting in less need for law enforcement.

Spring 2023 www.communitypsychiatry.org