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DilemmaRyuhei So M.D.
Okayama Psychiatric Medical Center
Introduction
• Schizophrenic patient are often assumed not to be competent to consent to their physical co-morbidity treatment.
• I encountered a dilemma between wish of schizophrenic patient’s with chronic kidney disease(CKD) and wish of his mother whether we start urgent dialysis or not.
ConsiderThe Indicationfor Dialysis
60 y.o. Male
60 y.o. Male
Chronic Kidney Disease
Drug Induced Acute Kidney Injury
60 y.o. Male
Chronic Kidney Disease
K 5.9mEq/L
Drug Induced Acute Kidney Injury
60 y.o. Male
Chronic Kidney Disease
K 5.9mEq/L
Drug Induced Acute Kidney Injury
60 y.o. Male
Chronic Kidney Disease
Schizophrenia
K 5.9mEq/L
Drug Induced Acute Kidney Injury
60 y.o. Male
Chronic Kidney Disease
Schizophrenia
exacerbation
K 5.9mEq/L
Drug Induced Acute Kidney Injury
60 y.o. Male
Chronic Kidney Disease
Schizophrenia
Bizarre behaviorexacerbation
exacerbation
Schizophrenia
Bizarre behavior
Conceptual disorganization
K 5.9mEq/L
Drug Induced Acute Kidney Injury
60 y.o. Male
Chronic Kidney Disease
TO DO OR
NOT TO DO
a facility for maintenance attend by a family member
• a facility for his maintenance dialysis
a facility for maintenance attend by a family member
• a facility for his maintenance dialysis• a family member for his attendant
a facility for maintenance attend by a family member
× ×a facility for maintenance attend by a family member
PUT IT ONTHE FAST TRACK
PUT IT ONTHE FAST TRACK
Tell his mother
PUT IT ONTHE FAST TRACK
Tell his motherConservative management
PUT IT ONTHE FAST TRACK
Tell his motherConservative managementFollow up
PUT IT ONTHE FAST TRACK
Tell his motherConservative managementFollow upGive up?
NOT TO DO!SOLVED!
MOVE BACKWARD
MOVE BACKWARD
MOVE BACKWARD
Inform himself
MOVE BACKWARD
Inform himselfEvaluate his competency
MOVE BACKWARD
Inform himselfEvaluate his competencyConference
MOVE BACKWARD
Inform himselfEvaluate his competencyConferenceReview board
The patient agree
The mother disagree
The patient incompetent?
The mother competent?
REALLY ?
Non-maleficence
Beneficence Justice
Autonomy
Four Principles of Beauchamp and Childress
Non-maleficence Difficulty in safety dialysis
Beneficence Justicescarce facilities for physical co-morbidity of schizophrenia
Autonomy disagreement
×
？
○
Four Principles of Beauchamp and Childress
No Absolute Answer
No Established Rules
Hesitation
a precedent in 199242 y.o. Female
exacerbation in CKD
dissociative disorder
confusion due to uremia
no disagreement
NOT TO DO
a precedent in 199242 y.o. Female
exacerbation in CKD
dissociative disorder
confusion due to uremia
no disagreement
NOT TO DO×
