Ethical considerations for the mentally unwell in a global pandemic
Submitted by Anthony Ragnauth
A recent ethical situation which came up in the past year was that of a public safety issue in a mentally unwell patient in the setting of a global pandemic. The ethical challenges in the care of this patient revolved around preserving patient autonomy, protecting the health and safety of the general public, all while trying to provide very good medical care to this person.
The background of the situation is as follows. The patient was a 33 year old gentleman with a history of paranoid schizophrenia and personality disorder. He had been living on the street for more than 10 years and was otherwise physiologically healthy at baseline. For the past month this patient had been checking in to the ED almost daily for assorted medical complaints. One day it would be for abdominal pain, the next day or day after would be for chest pain or back pain etc. The patient would typically be put in a room, and immediately start demanding food. After being seen by an ED provider and a workup ordered, the patient would demonstrate noncompliant and hostile behavior until his demands for food were met despite being educated on plan of care and NPO status. After the patient would realize he would not have his demands met he would begin destroying the equipment in his room. He pulled out IV lines and bleed everywhere without concern. He would be screaming, using obscenities, and declaring he was leaving AMA. This happened on several occasions and would end with pt being escorted off hospital property by security, only for him to return the following day.
On a recent ED visit, it was found out from the patient’s mother that he tested positive for COVID-19 at another hospital in the same week. The patient had nowhere to go and showed no interest in self isolating. After his customary demands for food and subsequent outburst, the patient tried leaving AMA again, which is where the ethical concern comes in strongly. The patient was a public health risk because of his infectious status, mental instability, and overall noncompliance with medical advice. A public health risk quarantine order was placed by the MD and the patient had to be restrained until treatment was complete. Of course, every effort was made to verbally de-escalate to preserve patient dignity and autonomy. This was fairly atypical, as normally restraints are reserved for confused patients who are unable to follow directions to promote medical surgical healing or are otherwise violently combative. After several hours when the patient was verbally amenable to follow the plan of care and cooperate with staff were his restraints released. He was able to eat, drink, and sleep comfortably after that while he waited for test results to come back. For a brief period the patient’s autonomy had to be safely overridden in the unique background of a global pandemic in the interest of public health. We had a duty to act with beneficence so the patient could recover although he might have been resistant due to his known mental instability. We practiced non malfeasance in using the least amount of aggression and escalating only when appropriate by attempting verbal de-escalation, redirection, and reorientation first and use of appropriate force only as much as necessary to make the patient safe in his mental state. The ethics of justice were also observed in our unbiased approach to this gentleman who had a history of verbal abuse towards staff, noncompliance, socioeconomic status, psychiatric history, etc. He was treated fairly with only his and the public’s best interest in mind. Every attempt within reason was made to benefit the patient even if he did not have the appropriate mental faculties to understand as much. He was discharged after stabilizing without any complications during his admission.