Decline of Treatment; Involuntary Commitment

Case Description: Decline of treatment; involuntary commitment 

Julia is an 18-year-old high school senior with a major depressive disorder. A teacher found her sitting in the school bathroom with an unopened bottle of powerful pain medication for which she does not have a prescription. When the teacher tried to speak with her about what is happening, she insisted, “I wasn’t going to do anything. Just leave me alone and pretend this never happened.” The school psychologist was called in and after evaluation expressed concerns about possible suicidal ideation. Julia, no longer a minor, did not want her parents called and would not commit to seeing her regular doctor, but reluctantly agreed to see you, a family practitioner certified in adolescent medicine, recommended by the school psychologist. Julia is surly but articulate. She claims treatment for her depression has always caused symptoms worse than the depression, and refuses to consider additional diagnostic tests or treatment options. She insists that though “everyone sometimes thinks of ending it” she wasn’t seriously considering suicide. 

What should you do? 

Discussion of Case: Decline of treatment; involuntary commitment 

Get the facts: 

Further fact-finding could greatly illuminate this scenario. Can you convince Julia to voluntarily allow the sharing of her previous pediatric and other health records, or to allow collaboration between you and other health providers who have treated her? What treatments were used in the past? Can you explore her relationship with her parents and family, encouraging her to allow their inclusion if they seem supportive? Can you learn if any social situation seemed a trigger for her recent despondency, or if there is no clear trigger? 

Identify tensions between ideals. 

In this case, tensions are exacerbated by the facts that the treating physician does not have a historical relationship with the patient, and the patient is still very young although not a legal minor. 

• Autonomy v. autonomy. You have no comparison base from which to assess whether Julia’s voiced views are consistent with others over time. Moreover, while the law treats childhood as over at 18, in fact different young people’s brains develop at different rates. Ethically, you may feel the need to “meet Julia where she is at” developmentally to the greatest extent possible. It may also be important to evaluate true adult decision-making capacity to evaluate the complaints about side effects and the seriousness of suicidal ideation. 
• Autonomy v. beneficence. Julia’s clearly stated decline of further evaluation and treatment may seem at odds with doing the best for the patient. So too might her desire to exclude family support, if it seems the family is both knowledgeable and supportive. 
• Autonomy v. norms of confidentiality. Respecting the confidentiality of sensitive health information shared with health providers is intimately linked to respecting patients as persons. In this case, you may feel tension between upholding patient confidentiality and the good for the patient that might come from insisting key supporters such as parents or previous healthcare providers be apprised of the perceived crisis. 
• Special harms of mental illness. The case is particularly acute because the greatest harm you feel possible, suicide, would be so catastrophic. 

Identify Options: 

• Try to solicit Julia’s voluntary cooperation in wider information-sharing, diagnosis, and treatment. 
• Respect Julia’s wishes for nontreatment and confidentiality, but let her know you would always be willing to talk to her if she continues to feel down. 
• Tell Julia that because you are concerned that she could harm herself and could be missing opportunities for improved treatment, you will consider coercive measures such as requesting a judge to authorize non-voluntary commitment if she does not “voluntarily” allow the sharing of past medical records and the notifying her family. 
• Seek a 72-hour non-voluntary commitment for emergency psychiatric evaluation from the court, requesting the court guardian to notify family and seek past medical records. 
• Other? 

Practice preventive ethics: potental strategies to avoid strict dilemmas. 

• You could encourage pediatric patients with serious mental health histories, during a relatively stable period as they are approaching the end of legal minorhood, to develop a psychiatric advance directive that outlines whom they want information shared among in case of mental health emergency, and whether there are any kinds of situations in which they would want someone other than themselves two take over their guardianship, and if so, who. 
• Keep the nonvoluntary commitment to the minimum time necessary to achieve patient safety. 
• Discuss your decision with the patient retrospectively, acknowledging your regret that you could not find non-coercive methods to keep the patient safe, in your view. 

If you interpreted the case as a strict dilemma, how could you minimize infringement? 

If you decided to seek non-voluntary commitment and forced evaluation/treatment, how might you minimize/repair infringement? 

If you used a psychiatric advance directive to authorize non-voluntary commitment and forced treatment: 

• Acknowledge that when you deem the patient more stable, and ask if, in retrospect, the patient thinks your interpretation accords with patient intent.