Four questions to guide clinical decisions
Consider the facts, the patient’s hopes and fears, and the concerns of others when making treatment recommendations
One could argue Mr. A might be incapable of making some treatment decisions, but simply recommending and pursuing guardianship is not the purpose of this quadrant.
2. What does the patient want?
Mr. A’s preference is not to take psychotropic medications because none helped in the past. His medical choice is clear: to have a total thyroidectomy. He is afraid of dying, explaining, “I don’t want them to leave any cancer in there.”
3. What kind of life does the patient both hope for and fear?
Although Mr. A generally rejects excessive intrusion into his life by the medical profession, he nevertheless takes HIV medications (albeit intermittently), wants surgery, and says he will take thyroid replacement medications. He is willing to tackle the issues he fears. He readily agrees to curative surgery for his thyroid cancer because he fears nothing more than dying of cancer.
4. Who and what else matters?
Besides the patient, the 2 people who matter most are the primary care doctor and the endocrinologist, who are concerned about Mr. A’s ability to take thyroid replacement therapy reliably. Their shared concern is based on the patient’s history of intermittent adherence to antiretroviral medications. Family does not figure in to Mr. A’s situation, as it usually does in cases such as this when family members are available to help the patient negotiate medical decisions.
Recommendation
The crux of the analysis is recognizing that a psychiatric intervention in the form of medication trials—even if a first-line treatment were clear—would be of uncertain benefit and involuntary psychiatric hospitalization would not accomplish the long-term goal of remediating Mr. A’s executive dysfunction. In the final analysis, the patient’s medical team accepted Mr. A’s wish for optimal medical treatment now, while accepting the uncertainty of his ability to follow through later.
Clinical outcome
Mr. A underwent a successful total thyroidectomy and is believed to be cancer-free. He continues to work with his infectious diseases doctor and endocrinologist; as expected, his adherence to thyroid replacement has been suboptimal. However, through occasional “loading doses,” Mr. A has managed to remain only mildly hypothyroid with no clinical sequelae.
Current Psychiatry ©2011 Quadrant HealthCom Inc.
