Re: Cause of death: Schizophrenia?

As a consultation-liaison psychiatrist who has practised on the medical and surgical wards of a busy teaching hospital for over 20 years, I thoroughly enjoyed reading the article from Ms Young and Dr Everett regarding an ethical approach for patients who have both life-threatening medical illnesses and severe mental disorders [BCMJ 2015;57:434-437]. The algorithm they provided is consistent with my approach. 

It was unfortunate that the management of the two complex cases they presented was not discussed in the article. The first case involved a patient who had both schizophrenia and was HIV-positive but denied having either illness and refused treatment for either of them. In my opinion it would be important to treat his HIV infection and reduce his viral load, even if he wasn’t certifiable for his schizophrenia, because of the potential harm to society if he was having unprotected sex. His delusion of not being HIV positive could be due to schizophrenia, CNS effects of his HIV infection, or other causes. Regardless, in my opinion the patient could be certified under the Mental Health Act and hospitalized because he has a mental illness and is at risk of harming others, as well as himself, due his delusional thinking and refusal to be treated for HIV. The question of whether the HIV infection could be treated against his will under the Mental Health Act would depend on whether his mental state was being significantly affected by the infection. The HIV infection, however, could be treated in hospital if he were found to be incompetent to make medical decisions regarding his care. The more significant difficulty with the case would be whether the patient could be forced to be treated long-term with antiretroviral agents, even if he were found to be incompetent of person and had a designated decision maker who agreed with his medical treatment. His schizophrenia could possibly be treated long-term against his will if he were placed on extended leave following his hospitalization. It is also possible that the patient might develop appropriate insight over time if his psychiatric illness were treated. The authors suggest that highly controversial options, such as deceiving patients (e.g., concealing medication in food), should be considered in complex cases. I agree that deceiving patients may be required in exceptional cases, but should rarely be used. Deception can become a slippery slope whereby patients lose all of their rights and autonomy and essentially become dehumanized. Even certified patients must be informed of the treatment they are being given. 

I would like to thank the authors for outlining their thoughtful approach for managing complex medical-psychiatric patients, and I would recommend that input from clinical ethicists be sought in these difficult cases.
—Stephen Anderson, MD, FRCPC 
Clinical Associate Professor, UBC Department of Psychiatry