Protecting the Vulnerable: The Challenges of Dialysis in the Mentally Ill
- Diversity and Equity in Kidney Health - II
November 04, 2022 | Location: Exhibit Hall, Orange County Convention Center‚ West Building
Abstract Time: 10:00 AM - 12:00 PM
Category: Diversity and Equity in Kidney Health
- 800 Diversity and Equity in Kidney Health
- Steinberg, Julie, Cohen Children's Medical Center, Queens, New York, United States
- Sparber, Lauren, Northwell Health, New Hyde Park, New York, United States
We present a case of a patient with mental illness who is refusing life-saving hemodialysis. The interdisciplinary moral distress experienced and the journey of managing chronic illness in the setting of psychiatric illness will be illustrated through the framework of ethical principles. This case brings to light several issues including the role of proportionality and social justice issues related to social determinants of health including potential social and/or moral health disparity.
We report a case of a 58 year old female with PMH of ESRD on dialysis (often non-compliant with dialysis), hypertension, hyperlipidemia and morbid obesity who presented to the ED with complaint of "vomiting blood". It is noted that when questioned the patient stated "they told me I was vomiting blood" and when asked to elaborate she stated the person she lives with told her this. Patient was admitted for treatment and management of severe electrolyte derangements secondary to non-compliance with hemodialysis and medications. Patient initially evaluated by Psychiatry and diagnosed with major depressive disorder. Throughout this lengthy complex hospital course it was evident that patient was becoming more delusional as she no longer believed she had renal failure despite ten months of dialysis.
The ethical analysis faces the substantial difficulty of balancing 3 bioethical principles in “managing” the patient’s renal disease: Beneficence, which leads her physicians to recommend hemodialysis due to ESRD; Respect for Autonomy, the patient’s own right to self-determination in matters related to the integrity of her body and self; and Non-Maleficence, the physician’s duty to “do no harm” by an intervention that has distinct risks, but without hemodialysis, the patient would face certain mortality. Individuals with mental illness should be afforded the opportunity to make their own health care decisions if they have the capacity to do so. In this case, the patient continues to lack insight into her medical condition. The patient’s genuine interest is served by continuing hemodialysis to prevent life threatening metabolic complications, attempting to restore capacity and intervening in her potentially treatable condition prior to her condition reaching life threatening urgency.