Lessons learnt in the end-of-life management of a hospice inpatient with advanced oropharyngeal cancer established on clozapine for treatment-resistant schizophrenia

Clozapine is a tightly controlled medication used effectively as a last-line agent in treatment-resistant schizophrenia, with a relatively narrow therapeutic window and significant interactions. Both underdosing and toxicity can be catastrophic to the patient. Patients with complex mental health illnesses are more at risk of head and neck cancers due to the high prevalence of associated risk factors including smoking, diet and alcohol. These patients also face barriers to accessing and using healthcare and may not tolerate procedures for artificial routes for feeding and medications. As the disease progresses, these patients are vulnerable to clozapine toxicity from factors such as constipation, reduction in cigarette smoking, weight loss and medication interactions. Conversely, they also risk underdosing with a relapse of distressing psychotic symptoms as the swallow deteriorates. This case highlights the need for considerate planning, prescribing, close monitoring and awareness alongside the importance of multidisciplinary working when caring for this patient group.