(213) An Approach to Refusal of Care in Antepartum Mental Health

Location: Griffin Hall

Trainee Involvement: Yes

Presenting Author(s)

MS

Minjoo Son, MD

Resident
University of Illinois at Chicago
Chicago, Illinois, United States

Co-Author(s)

CS

Chad A. Stephens, MD

Resident
University of Illinois at Chicago
Chicago, Illinois, United States
AM

Ashley Mulvihill, MD

Attending Psychiatrist
University of Illinois at Chicago
Chicago, Illinois, United States

Background:
Health care providers may be apprehensive about addressing acute psychiatric illness in the peripartum period due to limited research, evolving safety data on psychotropic medications, and gaps in discussion on ethical dilemmas involving risks to patient and fetus (Robinson, 2012). While autonomy, beneficence, justice, and nonmaleficence are the cornerstones of medical ethics, balancing these principles becomes complicated in clinical situations that appear to pit the needs of the pregnant patient against the needs of the fetus (Miller, 2009). We present two cases of patients hospitalized for acute schizophrenia refusing medical care in the setting of high-risk pregnancy and propose a generalizable framework to approach complex decision-making involving patient and fetus.

Case 1:
A G3P2002 female in her thirties at 27 weeks gestational age with schizophrenia and untreated HIV was hospitalized for acute psychosis. Patient initially exhibited delusions that she did not have HIV or need antiretroviral medications. Treatment with court-ordered risperidone improved the patient’s ability to accept and engage in her medical and obstetrical care. She became amenable to starting HIV medications and was increasingly able to participate in discussions on her birth plan with the goal of minimizing HIV transmission to her fetus.

Case 2:
A G3P1102 female in her thirties at 25 weeks gestational age with schizophrenia and pulmonary hypertension was hospitalized for acute mood and psychotic symptoms and treated with risperidone. Although the patient lacked insight into an increased mortality risk due to her pulmonary hypertension without pregnancy termination, she consistently expressed the preference to proceed with her pregnancy. With treatment of the patient’s psychiatric symptoms, she engaged in multidisciplinary care with Psychiatry, Maternal-Fetal Medicine, and Pulmonology. Patient ultimately agreed to start medications to treat her pulmonary hypertension with the goal of planning for the safest delivery possible.

Framework and

Discussion:
We propose and discuss a framework (diagram to be included in poster) when approaching complex decision-making involving patient and fetus. Specifically, we focus on situations in which pregnant patients choose to refuse medical and prenatal care because their capacity is affected by decompensated psychiatric illness. Our framework utilizes concepts of substituted judgment, directive counseling, omission bias, relational ethics, and justice.

Conclusion:
Complex ethical dilemmas in perinatal psychiatric care can be reframed to respect patient autonomy, maximize benefit to patient-fetus, and limit risk. Treatment of acute psychiatric illness affecting decision making capacity, sensitive use of directed counseling, relational ethics, and ample emphasis on the benefits of a proposed treatment help to promote autonomous, informed decisions regarding medical care. Increased attention to ethical issues in perinatal mental health is needed to improve provider knowledge and confidence when treating this population.

References:
Robinson G. E. (2012). Treatment of schizophrenia in pregnancy and postpartum. Journal of population therapeutics and clinical pharmacology = Journal de la therapeutique des populations et de la pharmacologie clinique, 19(3), e380–e386.

Miller, L. J. (2009). Ethical issues in perinatal mental health. Psychiatric Clinics of North America, 32(2), 259–270.