P13: From Crisis to Care: Implementing Shared Decision-Making in Psychogeriatric Practice

Abstract

Objectives: Shared decision-making (SDM) is a promising approach to promote patient and person-centeredness in psychiatric clinical practice. Despite being an ethical requirement, implementing SDM might be challenging, particularly for patients with severe mental illnesses who may not always be recognized as having decision-making capacity, leading to physicians often taking control.

Methods: Case Report.

Results: Mrs. D, an 84-year-old Caucasian woman with a history of multiple depressive episodes since age 24 and hypertension, was brought to the Emergency Department by her daughters due to weight loss, depressed mood, hopelessness, anhedonia. She repeated that she had no heart and expressed fears of being hospitalized, believing doctors would remove her organs, which were no longer working, and described her arms as crumbling like sand. She was initially assessed for food refusal and delusional nihilistic thoughts, which started four months prior to presenting to the hospital after discontinuation of lithium carbonate due to intoxication and got progressively worse.

The patient met the criteria for MDD with Cotard Syndrome. Recommended treatments included ECT and pharmacotherapy. During her first ECT session, she presented a 10-second post-seizure asystole. After reevaluating her treatment, her daughters asked about alternatives. Although there were no contraindications to ECT treatment, the team, in collaboration with family members, explored options. A therapeutic strategy with venlafaxine, mirtazapine, olanzapine, aripiprazole, lithium carbonate, subcutaneous dextrocetamine was implemented.

Two months later, following 15 dextrocetamine infusions, she showed partial resolution of symptoms and was discharged with no delusional content in speech. She continued outpatient dextrocetamine infusions and achieved complete symptom remission within six months, regaining her autonomy and returning to gardening. After remission, the patient expressed a desire to avoid ECT if possible, should it be indicated in the future.

Conclusions: This report highlights the potential of SDM to explore and discuss scenarios during the informed consent process and gather information on the patient’s preferences in the event of a temporary decrease in capacity. SDM with elderly can be supported by advance care planning and directives, decision aids, training clinical staff, encouraging patient questions. Key steps include creating decision aids, training staff, and familiarizing older adults with SDM.