Journal of Clinical Studies & Medical Case Reports Category: Medical Type: Case Report
Autonomy and Capacity in Transitional Age Youth (TAY) with Serious Mental Illness: Challenges in Mental Health - A Case Report
- Andrea P Mendiola Iparraguirre1, Timothy Van Deusen1*
- 1 Department Of Psychiatry, Connecticut Mental Health Center, Yale School Of Medicine, New Haven, United States
*Corresponding Author:Timothy Van Deusen
Department Of Psychiatry, Connecticut Mental Health Center, Yale School Of Medicine, New Haven, United States
Received Date: Dec 09, 2019 Accepted Date: Dec 17, 2019 Published Date: Dec 23, 2019
Objective: An admission to a medical or psychiatric inpatient unit is a difficult time during a Transitional Age Youth (TAY)’s life. While some patients recognize the need for their admission, severely ill patients lack insight into their illnessand require involuntary hospitalization, which may impactthe patient’s quality of care, patient-doctor relationship and raise legal and ethical questions to patient’s autonomy, capacity, and their wishes.
Methods: Describe the legal and ethical challenges of TAY with serious mental illness and multiple physical illnesses; illustrated by a clinical case.
Results: TAYis affected by legal issues involved with treatment in this population, including a patient’s right to refuse treatment, involuntary commitment versus court-ordered treatment, advance directives, health care proxies, and confidentiality.
Conclusions: It is critical to recognize the ethical and legal issues encountered by TAY with serious mental illness. Understanding these matters will improvethe provider’s care and enhance their ability to advocate for patients’ rights.
- About 75% of all psychiatric illnesses occur by age 24; early intervention in TAY (16-25 years old) is critical in this vulnerable population
- Physicians play a significant role in assessing capacity, providing advice, guidance and support to the surrogate, conservator or judicial authorities
- Autonomy and capacity are complex topics in general and applying them to TAY carries multifaceted challenges that will be encountered mainly during involuntary admissions, decompensation due to medication non-adherence and refusal to accept treatments
The transition in care for the Young Adult or Transitional Age Youth (TAY) population - usually defined as between ages 16 to 25 years old - has been characterized as challenging in both physical and mental health care . Reaching the age of majority (18 years old) implies an increase in independent behavior and personal autonomy , which has significant implications for medical and mental health treatment choices. In a longitudinal cohort study by McMillen, et al., 325 young adults between ages 17 to 19 were interviewed about their use of mental health services. They showed that comparing the services received as minors versus 18 years old, that 11% continued receiving mental health services, and only 19% of patients continued taking their prescribed psychotropic medications . The primary reasons for stopping medications were “not liking to be on medications” or “thinking that they do not need them” . Studies have shown that once youth understand they have achoice, not the parent’s, case manager’s or foster parents, they tend to stop taking their medications; this is consistent with research with young people in the foster care system which showeddissatisfaction with the way their psychotropic medications were prescribed .
TAYs are in a critical period for treatment interventions. They can exercise their autonomy concerning treatment decision-making, which opens up ethical and legal challenges for clinicians working with this vulnerable population. The authors report a case that highlights these issues in a young adult with serious mental illness and multiple medical comorbidities. Some of the demographic information has been altered to protect the patient’s autonomy; we will name the patient “K” for the same reasons.
K presented to the Emergency Room (ER) in July of 2018 with persecutory delusions in the context of medication non-adherence (valproic acid and chlorpromazine) and was admitted for a month on the psychiatric inpatient unit. He was re-started on his medications and discharged to his family with the plan of resuming care with his outpatient program. Five days after K’s discharge, he voluntarily returned to the ER seeking help after he had stopped all his medications and had been using alcohol and other substances. He presented with psychosis, mainly paranoia, word salad and florid neologisms. A full medical workup was conducted, including brain images, electroencephalograms, and inflammatory markers, and these studies did not show any abnormality. Clozapine was added to his medications and an application for Conservatorship was considered as his extended family could no longer care for him due to his non-adherence to medications and his chaotic, dangerous behaviors. The Conservatorship application was not completed since K demanded his discharge, and since he was admitted under voluntary status, he was discharged to a transitional living facility. At this new residential facility, K continued to abuse substances and stopped taking his psychiatric medications as well as medicines for diabetes, hypertension and asthma. A week later, K was readmitted to the hospital for medical issues requiring treatment in an Intensive Care Unit (ICU), diagnosed with diabetic ketoacidosis and necrotizing pancreatitis. During this hospitalization, he was admitted to the medical unit and received psychiatric care from the Consultation and Liason team. It was considered K’s capacity to consent for surgical drainage of pancreatic abscesses, anticoagulation therapy and treatment, in general, was intact, yet refused his psychiatric medications. K agreed with all medical treatment recommendations and made decisions for his health and disposition plan; however, he continued to have persecutory delusions and prominent thought disorganization, which included word salad and neologisms. Once medically stable, K was transferred to a psychiatric inpatient unit and a few weeks later to a psychiatric state hospital under voluntary status for a prolonged admission. He is currently receiving clozapine and ECT with only partial remission of his symptoms. K’s psychiatrist has recommended that a conservator be appointed for assistance with medical decision making and a representative payee for the administration of his finances and benefits.
It is noteworthy that no particular psychiatric or medical illness automatically leads to one’s incompetence. The decision is based on a clinical capacity assessment and a judge’s decision should determine competent or incompetent functioning . Nevertheless, mental health issues can affect the patient’s judgment and capacity and assessed as “incapable of making independent decisions.” In those cases, patients might benefit from “support decision making,” which is based on autonomy and provides support to people whose decision-making ability is impaired to enable them to make their own decisions whenever it is possible . However, other groups of patients affected by severe mental illness cannot make judicious decisions on their own.
The medical ethics, as embodied in the American Medical Association’s Code of Medical Ethics, makes clear that while the autonomy of competent individuals must be respected, irrational or otherwise impaired individuals are not considered autonomous agents . As such, a surrogate decision-maker may be appointed to overrule the decisions of an incompetent patient . The assessment of mental capacity can center on judicial intuition as much as on medical evidence . Therefore physicians play a significant role in assessing capacity, providing advice, guidance and support to the surrogate, conservator, or judicial authorities . During K’s inpatient admissions to the medical and psychiatric units, communication with inpatient treaters was essential in order to provide collateral information, previous medication trials and to discuss treatment plans and disposition; the physician liaison role with other providers is fundamental in high complexity cases . These issues become mainly involved in the context of TAY, where autonomy and capacity are new concepts based on their chronological age.
During the course of K’s hospitalization, multiple instances occurred when his capacity might have been questioned. K often made decisions on his own, including all the times when he looked for help in the ER, asked for medications and treatment to help with his symptoms and agreeing to surgical drainages, or when he chose to be discharged to supportive housing instead of his extended family. Most of these decisions have a positive impact on his health. However, in other instances, K made decisions that had negative consequences, such as demanding for his early discharge from inpatient psychiatric units, declining to take psychiatric medications when the Consultation and Liason team recommended it, or when K stopped taking his medications after beings discharged to home. Moreover, in other circumstances, K’s capacity was assumed and a detailed assessment was not conducted, as when he received ECT during one of his last inpatient admissions. All the situations mentioned exemplifying some of the challenges encounters when treating patients with mental health issues are essential to understand the importance of prompt assessment for capacity and to take into consideration the elements necessary to ensure the appropriate care, such as considering tools like conservatorship or guardianship.
Conservatorship or guardianship has been established in multiple states in the United States as a way of guaranteeing the best decisions for patient’s health care. The goal of supervising and making health decisions for patients without capacity is to decrease relapses and help the patient reintegrate into society. Chronic illness, including mental health, in young adults, is a well-recognized cause of disability, mental health sequelae, educational and occupational limitations, and financial hardship .
In the case mentioned above, K viewed autonomy as an achievement he gained over the years and as the ability to do everything he pleased. However, the decisions he made under his autonomy were not the best for his health; some of them resulted in detrimental effects on his health, such as obesity and diabetes.
Applying, or even considering conservatorship, could be detrimental to the doctor-patient relationship. Researchers have shown definitively that the therapeutic working alliance between patient and practitioner as the single most crucial factor in the treatment of mental health . However, weighing risks and benefits must always direct care to the best outcome ina patient’s health.
A case series of 17 patients from a Veterans Administration Hospital highlighted the importance but circumscribed effects of being conserved. The report found evidence that having a conservator seems to improve patient’s access to necessities, notably shelter; however, it did not find any effect on clinical relapses into psychosis or substance abuse .
Autonomy and capacity are complex topics in general, and applying them to TAY carries multifaceted challenges that will be encountered mainly during vulnerable times. These include involuntary admissions, decompensation due to medication non-adherence, and refusal to accept treatments.The paucity of research published about this topic in the TAY population makes the matter more daunting. See Table 1 for recommendations when working with TAY that suffer from severe mental illness admitted to the inpatient medical or psychiatric unit.
1. Consider frequent assessment of capacity
2. Implement a patient-centered treatment plan with recovery as a goal of remission of symptoms and restoration of functioning 
3. Discuss risks, benefits, alternative options directly and frankly with the patient
4. If the patient is found to not have capacity: consider early involvement of the family or guardian to help make decision, and in the cases with absence of family, to petition the courts to appoint a conservator early in the course of treatment
DISCLOSURES AND ACKNOWLEDGMENTS
- Wilens TE, Rosenbaum JF (2013) Transitional aged youth: a new frontier in child and adolescent psychiatry. J Am Acad Child Adolesc Psychiatry 52: 887-890.
- de Girolamo G, Dagani J, Purcell R, Cocchi A, McGorry PD (2011) Age of onset of mental disorders and use of mental health services: needs, opportunities and obstacles. Epidemiology and Psychiatric Sciences 21: 47-57.
- Jones PB (2013) Adult mental health disorders and their age at onset. Br J Psychiatry Suppl 54: 5-10.
- Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, et al. (2005) Lifetime Prevalence and Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 62: 593-602.
- McMillen JC, Raghavan R (2009) Pediatric to adult mental health service use of young people leaving the foster care system. J Adolesc Health 44: 7-13.
- Reiss J, Gibson R (2002) Health Care Transition: Destinations Unknown. Pediatrics 110:1307-1314.
- Lee BR, Munson MR, Ware NC, Ollie MT, Scott LDJ, et al. (2006) Experiences of and Attitudes Towards Mental Health Services Among Older Youths in Foster Care. Psychiatr Serv 57: 487-492.
- Frank JB, Degan D (1997) Conservatorship for the Chronically Mentally Ill: Review and Case Series. Int J Law Psychiatry 20: 97-111.
- Davidson G, Kelly B, Macdonald G, Rizzo M, Lombard L, et al. (2015) Supported decision making: A review of the international literature. Int J Law Psychiatry 38: 61-67.
- AMA (2017) Code of Medical Ethics. American Medical Association, Chicago, USA.
- Hartman B (2009) Conservatorship of Burton: Mental Illness and the Right to Refuse. J Law Med 37: 380-382.
- Noblett J, Caffrey A, Deb T, Khan A, Lagunes-Cordoba E, et al. (2017) Liaison psychiatry professionals' views of general hospital care for patients with mental illness: The care of patients with mental illness in the general hospital setting. J Psychosom Res. 95: 26-32.
- Ewais T, Banks C (2018) Health and justice partnerships for young adults - when health and law unite in care. Health Education Journal 77: 656-666.
- Osborn LA, Stein CH (2019) Recovery-oriented services in an inpatient setting: The role of consumers' views of therapeutic alliance and practitioner directiveness on recovery and well-being. Am J Orthopsychiatry. 89: 115-123.
- Davidson L, Lawless MS, Leary F (2005) Concepts of recovery: competing or complementary? Curr Opin Psychiatry 18: 664-667.
Citation:Iparraguirre APM, van Deusen T (2019) Autonomy and Capacity in Transitional Age Youth (TAY) with Serious Mental Illness: Challenges in Mental Health - A Case Report. J Clin Stud Med Case Rep 6: 077.
Copyright: © 2019 Andrea P Mendiola Iparraguirre, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.