(135) Terminal Delusional Disorder: A Case for Compassionate End-of-Life Care

Abstract:

Background: Delusional Disorder (DD) is characterized by a persistent fixed false belief despite contradictory evidence. This case presents a terminal somatic type DD in a 58-year-old female, convinced an underlying medical condition is causing inability to tolerate oral intake.

Case: GC, a 58-year-old female, was admitted to a general medicine service with severe malnutrition and significant weight loss, exacerbated by an acute inability to tolerate oral intake. Symptoms upon attempted eating include chest tightness, headaches, tachycardia, chills, and burning sensations in her nose and eyes. She attributes her intolerance to an undiagnosed autoimmune condition and chronic Lyme disease, although exhaustive workup from multiple specialists at different institutions has failed to elucidate any underlying cause. Following psychiatric evaluation during this hospitalization, she received a diagnosis of delusional disorder. Notably, her husband shares her delusional beliefs, suggesting a folie à deux. Given the complexities of her condition, including profound intolerance to food, fluids, and medications as well as her husband's shared delusional beliefs, ethical dilemmas arose regarding the appropriateness of interventions and the patient's autonomy. An Ethics consult deemed forced interventions were unethical but supported continuation of IV fluids with dextrose and electrolyte supplementation as desired by patient. Following a 51-day hospitalization, she was discharged to hospice care, still receiving supplemented IV fluids.

Conclusion: Severe Delusional Disorder can lead to profound nutritional intolerance, necessitating hospice involvement for end-of-life care. Delusional disorder leading to severe malnutrition acts as the qualifying hospice diagnosis, thus her condition can be considered a terminal psychiatric illness. This case underscores the complexities involved in treating psychiatric conditions that significantly impact an individual's quality of life and highlights the importance of adopting comprehensive, interdisciplinary care approaches (Shalev et al, 2023). Further research is imperative to explore effective interventions for managing severe DD and improving outcomes for individuals with this debilitating condition. Moreover, addressing the ethical considerations inherent in providing end-of-life care to psychiatric patients is crucial (Brown and Trust, 2023). Providing hospice care to individuals with severe psychiatric disorders raises questions about the appropriateness of end-of-life interventions, the allocation of resources, and the deliberation of ethical principles. In this case, decisions regarding hospice care necessitated careful consideration of the patient's wishes, quality of life, and prognosis, while balancing the principles of autonomy, beneficence, and non-maleficence. By acknowledging and addressing these ethical complexities, healthcare professionals can ensure that end-of-life care decisions are arrived at in collaboration with the patient, thus respecting their autonomy and dignity. Additionally, ongoing research and dialogue in this area are essential for developing guidelines and protocols that promote ethical and compassionate care for individuals with severe psychiatric conditions requiring end-of-life management.

References:
1. Brown VA, Trust A. What makes palliative mental health ethical health care? AMA Journal of Ethics. September 2023; 25(9):E674-677.
2. Shalev D, Brenner K, Carlson RL, Chammas D, Levitt S, Noufi PE, Robbins-Welty G, Webb JA. Palliative Care Psychiatry: Building Synergy Across the Spectrum. Current Psychiatry Reports. 2024; 26:60-72.

Presentation Eligibility: Not previously published or presented.

Diversity, Equity, and Inclusion: This submission highlights the challenges in providing hospice care to individuals with severe psychiatric disorders, emphasizing the need for equitable access and culturally competent care. It underscores the importance of interdisciplinary approaches and ethical considerations in ensuring compassionate end-of-life management. By promoting inclusivity, patient autonomy, and dignity, it contributes to Diversity, Equity, and Inclusion (DEI) in healthcare.