LAUSR

“Mr K” was a 65-year-old African American male, nursing home resident, with a past medical history of persistent schizophrenia, hemodialysis-dependent end-stage renal disease (HD-ESRD), hypertension, and type 2 diabetes mellitus. He had been refusing dialysis for around 6 months and was administered intramuscular psychotropic medications (5mg of haloperidol, 2mg of lorazepam, 50mg of diphenhydramine) prior to all hemodialysis sessions while he was living at his nursing home. He was admitted for catheter replacement, having pulled out his vascular access for the fourth time in the past 5 months. During the current admission, he demonstrated a general resistance to treatment; not only refusing replacement of the dialysis catheter but also resisting laboratory tests and vital signs. He had been without dialysis for 4 days at the time of interview. He, however, continued to compliant with all his medications and nursing care. A psychiatry consult was requested to evaluate for Mr K’s decision-making capacity and for recommendations if his long standing mental illness was playing a role in his refusal of treatment. Mr K was unable to provide most of his history. Court records revealed a 30 year history of severe mental illness which included numerous involuntary hospitalizations as well as a succession of court-appointed guardians, the first of which was appointed when the patient was just 26 years old. He remained legally incompetent with a legal guardian in place at the time of consultation. His most recent psychotic symptoms, as per report of the psychiatrist who had been seeing him at the nursing home, consisted of auditory hallucinations and paranoid delusions which responded to his current haloperidol dose of 10 mg. He was reported to be in adherence with his medication. His positive psychotic symptoms were stable with treatment. As per his outpatient psychiatrist, the patient at least had trials of quetiapine and risperidone in the past, started by different providers, at appropriate doses and with remission of positive symptoms. No further collateral information was available as there had been no family involvement in Mr K’s life for many years. Mr K had been consistent regarding his refusal of dialysis. Further questioning revealed that he understood neither the nature of his illness nor the ramifications of his continued refusal of treatment. He stated that he would continue to remove the catheter as he found it irritating; however, he denied any problems with his kidney function and stated that he would continue to live even without dialysis. At no point during the initial exam or subsequent follow-up visits was he observed to have Correspondence to: Shehryar Khan, M.D., Henry Ford Hospital, 2799 W. Grand Blvd., Detroit, Michigan 48202, USA. E-mail: [email protected] Disclosures: The authors report no financial relationships with commercial interests. Conflict of Interest: None.