End-of-Life Planning for Forensically and Civilly Committed Psychiatric Patients

Abstract

Purpose

An overlooked reality of treating patients with severe mental illness in mandated inpatient hospital settings is the inevitable confrontation of end-of-life care and medical treatment. Many psychiatric patients who are seriously ill are not capable of deciding on treatment or identifying a person responsible to make medical decisions for them creating many legal, clinical, and bioethical issues. This study identifies psychiatric patients at a state psychiatric hospital that are at risk for end-of-life treatment and intervention and evaluates the quality of their plan for medical treatment in relationship to their psychiatric diagnosis, alcohol abuse diagnosis, substance abuse diagnosis, and legal commitment.

Design and Methods

The authors used a cross-sectional study in 2017 and reviewed charts (n=320) of medically fragile and elderly psychiatric patients mandated to mental health treatment at a state psychiatric hospital for presence and quality of an end-of-life treatment planning which includes an advanced health care directive AHCD, a do not resuscitate (DNR) order, and a physicians order of life sustaining treatment (POLST). The authors obtained institutional data collected by the hospital via chart review administered through the social work department.

Results

Advanced Health Care Directive assessments revealed that of the 320 patients sampled (M age = 67, SD = 5.68) their average length of stay at the hospital was 5.83 years (SD=8.88). Major psychotic disorder was the most common category of diagnosis (n=228), followed by major mood disorder (n=16), and neurocognitive disorder (n-14). Of the 320 patients reviewed 29% were diagnosed with comorbid alcohol abuse disorder (n=92) and 23% were diagnosed with a comorbid substance abuse disorder (n=73). Over half the patients sampled had some form of contact with a member of the community (n=184). Of the patients sampled 64% (n=114) had a least one form of end-of-life planning; 37% declined to sign an AHCD (n=117), and less than 1% was noted to not have capacity. Lastly, 19% of the patients reviewed for this study were civilly committed, whereas the reaming 81% were forensically committed.

Implications

To our knowledge, this is the first study to explore the quality of end-of-life care planning among persons with serious mental illness within a forensic psychiatric hospital. The results suggest that despite legal requirements to ascertain end-of-life plans for mandated psychiatric patients there gaps in medical advance care planning for this population. As wards of the state, medical advance directives for persons mandated to treatment at state facilities is an important legal and ethical issue. However, due to many factors including lack of access, knowledge regarding end-of-life planning for this population significantly lags behind the general population. Although this paper presents initial findings, it is unclear whether psychiatric diagnosis or lack-of-community ties impede end-of-life care planning. Further examination in well-designed research evaluations is required to build a body of knowledge that will be helpful in understanding the effective implementation of end-of-life planning for this specific population.