Treatment over Objection Versus Withdrawal of Dialysis in Cases of Severe Mental Illness

AbstractPatients with severe mental illness are more likely to develop kidney disease and its complications compared to patients without severe mental illness. Once patients with mental illness develop end-stage kidney disease, supporting adherence is important but can be difficult in moments of acute psychosis when the patient objects to dialysis, particularly when considering the lack of dialysis-compatible psychiatric hospitals. In this case, a woman with a history of bipolar disease and end-stage kidney disease has a manic episode after discontinuing her antipsychotic medications and refuses dialysis owing to paranoid delusions. We argue that, due to the potential imminent harm to the patient in refusing dialysis when incapacitated due to severe mental illness, it is reasonable to pursue treatment over objection while waiting for return to capacity unless the surrogate decision maker does not believe it would be in line with the patient's values and beliefs. If there is no return to capacity after an agreed trial period and dialysis cannot be safely pursued outside of the hospital, the provider may ethically withdraw dialysis even contrary to the surrogate decision maker when continuing treatment may be limited by resources and overshadowed by harm to the patient. In this article, we will discuss how Rubin and Prager's criteria in deciding to treat over patient objection were used and their limitations in being able to quantifiably weigh each principle, as well as the ethical justifiability of withdrawal of dialysis should the patient continue to be decapacitated and unwilling to cooperate with dialysis.