(232) The Case of an Incapacitated Patient with Peripartum Psychosis: Navigating Care Dilemmas and Strategies for Advance Care Planning

Abstract:

Background:  Peripartum psychosis is associated with higher risk of adverse obstetric and neonatal outcomes.¹ When peripartum patients with worsening psychosis are found to lack capacity, the psychiatrist and obstetrician (OB) are faced with ethical, legal, and practical challenges. We present the case of an incapacitated peripartum woman with unspecified psychosis, including ethical conflicts and recommendations for advance care planning.



Case: Ms. A is a 32-year-old woman who presented to OB clinic for abdominal pain, found to be 12 weeks pregnant. Over her pregnancy course, she exhibited paranoid delusions and auditory hallucinations, with fair participation in prenatal care. She declined antipsychotic treatment due to concerns for adverse fetal effects. On the day of her scheduled Cesarean section (C-section), she requested specific areas to be anesthetized though it was not anatomically feasible. She was determined to lack capacity to refuse the C-section and anesthesia options. She cited her surrogate decision maker as the newborn’s father, who consented to the procedure. She had a successful delivery and was subsequently admitted to the inpatient psychiatry unit for ongoing psychosis. The father/surrogate was later discovered to be a known registered sex offender and banned from the hospital, and Child Protective Services was involved. Important steps were taken to ensure the safety of the newborn, who was kept away from the father. After inpatient psychiatric treatment, the patient was discharged with outpatient mental healthcare.



Discussion: This case illustrates ethical dilemmas associated with capacity assessments in peripartum psychosis and surrogate selection. Ms. A’s refusal of a high-risk, high-benefit treatment warranted a medium threshold for capacity.² Given that she was an adult with capacity to nominate a surrogate, the care team respected her wishes to let the newborn’s father make medical decisions regarding the procedure.³  To circumvent future care dilemmas, we propose a novel Advance Care Planning Checklist developed and implemented at one county hospital, which guides OB and psychiatrists through medical-legal considerations, capacity assessments, and patient preferences for the pre-pregnancy, pre-delivery, intrapartum, and postpartum periods. Advance care planning for reproductive decision-making prior to an incapacitating mental health crisis aims to better preserve patient autonomy.⁴

Conclusion/Implications: Incapacitated patients with peripartum psychosis present dilemmas associated with capacity assessments and surrogate selection. The consult-liaison psychiatrist is pivotal in establishing institutional algorithms for navigating ethical-legal aspects of decisional incapacity. Furthermore, using an Advance Care Planning Checklist has potential to prevent care dilemmas and enhance collaborative care between OB and psychiatry teams.


References:

1. Zhong Q-Y, Gelaye B, Fricchione GL, et al. Adverse obstetric and neonatal outcomes complicated by psychosis among pregnant women in the United States. BMC Pregnancy Childbirth. 2018;18(1):120. doi:10.1186/s12884-018-1750-0


2. Magid M, Dodd M, Bostwick J, et al. Is your patient making the “wrong” treatment choice? Curr Psychiatr. 2006;5(3):13-20.


3. Syed S, Sachinvala N, Salman J. Mother or fetus? Where do our obligations lie? Am J Forensic Psychiatry. 2010;31(4):31-46.


4. van Bockxmeer JJ, Haining CM, Atkinson A. Advance care planning for pregnant patients. Med J Aust. 2023;218(4):161-164. doi:https://doi.org/10.5694/mja2.51820

Presentation Eligibility: Not previously published or presented.

Diversity, Equity, and Inclusion: This case exemplifies the role of consultation-liaison psychiatrists in strengthening institutional reforms and perinatal collaboration for marginalized groups at a county hospital. Perinatal mental illness disproportionately impacts minority groups, including non-Hispanic Black and socioeconomically disadvantaged individuals. Our patient represents multiple identities and structural barriers: female of Latin American ethnicity, with severe mental illness and Medicaid insurance. Additionally, advance care planning (ACP) has been underutilized in patients with limited English fluency (Ashana et al., Journals of Gerontology, 2022). As this hospital serves primarily Spanish-speaking, underinsured communities, our case calls for greater integration of ACP for individuals with limited care access.