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Hiding behind `free will'

Are laws protecting the right to refuse psychiatric treatment doing more harm than good?

June 10, 2007|Susan Partovi | SUSAN PARTOVI is a staff physician at the Venice Family Clinic and an assistant professor at UCLA's David Geffen School of Medicine. She is also the medical director for Homeless Health Care Los Angeles.

THE PHONE RANG at 3 a.m. "Dr. Partovi," the person on the line said, "I'm calling to let you know that William expired this morning."

I'd first met William about six months earlier in May 2006 at the Venice Family Clinic after his release from a hospital where he was treated for congestive heart failure. I still remember his loud, childlike voice: "No, no ... I'm not going to the hospital!" he shrieked when I told him that I wanted to refer him to Harbor-UCLA's cardiology clinic.

William -- I'm calling him that because medical privacy rules don't allow me to use his real name -- was 61. Six feet tall with gray hair, he dressed in T-shirts and pants that were a little too big. He lived alone in an apartment in Brentwood and had a sister in Canada and a niece in New Jersey.

Three years earlier, he'd had a heart attack and a stroke, and he now suffered from dementia, likely as a result of the stroke. It was quickly obvious to me that William could not take care of himself anymore. He spoke like a whining toddler. He was very stubborn, and his judgment was extremely limited. "My memory's not good," he'd huff if he couldn't answer a question.

But one's inability to care for oneself is not a criterion to receive involuntary treatment for the mentally impaired. And for many mentally impaired people without family nearby to rely on for housing, food and help in managing their medical care, the result can be disastrous.

A recent study of adults with serious mental illness who were treated in eight states' public hospitals and clinics found that they died, on average, at age 51 -- 25 years younger than the average American. The study's lead author, Dr. Joseph Parks, director of psychiatric services for the Missouri Department of Mental Health, said that about three out of five died of preventable diseases.

William's heart failure was very treatable, but only if he would take his medications appropriately.

I continued to see him every two weeks or so at the clinic. At first he was brought by a female friend, and then after she disappeared, by a new friend, Mike. Mike kindly made sure that William had food, checked that his bills were in order and put his medication into daily pill boxes. When, after a few months, Mike confessed that he'd met William only recently when buying one of his boats and couldn't continue to be this involved, I understood.

I asked one of the clinic's volunteer psychiatrists to see William, and she chatted with him for a bit during his regular clinic appointment with me.

Though he seemed to like her, he would never go to her office at the Edelman Westside Mental Health Center, a county clinic, and neither of us could make him go. I also called the county office that handles elder services -- which investigates impaired adults to learn whether they suffer from abuse, isolation or neglect -- but he kicked the social workers out. "He's got a personality problem," one of the social workers said to me afterward. "We can't help him."

William's health deteriorated, and he landed in the emergency room with abdominal pain -- most likely angina related to his heart failure. I asked for a psychiatric consultation; if William were deemed incapable of making his own decisions, we could try to get him placed in a long-term care facility.

But the hospital psychiatrist claimed that William knew his name and where he lived -- and that he was very insistent on not being placed.

"But he can't take care of himself, he doesn't have food, he can't pay his bills, he won't take his medications," I replied.

"It's his free will to not take his medications." Thus, he was deemed "fully competent."

A woman who'd been assigned by the hospital to sit with William in his room took it upon herself to become his home health caretaker after he was released. She cleaned his apartment -- which she described as unlivably filthy -- washed his clothes, stocked the fridge. But it lasted only three days. He became so verbally abusive that she left.

Mike called a few days after that. He'd found William naked on the couch, claiming that he couldn't find anything to wear.

I thought that he should go to Harbor-UCLA Medical Center, where I could try to get another psychiatric consultation. Mike agreed to take him, but William refused to go.

He'd still come to his now-weekly appointments at the clinic, but he stopped taking the drugs that controlled his blood pressure, cholesterol, fluid levels and agitation. He would only say, "I promise, Dr. Partovi, I'm going to do better," like a 3-year-old promising not to hit his sister.

The next phone call came from his landlord. "William looks very sick," she said, "but he won't go to the hospital."

When I called to check on William, he sounded breathless. Yet, when I mentioned the hospital, he slammed down the phone.

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