一名29岁的东非女性难民,没有正式的精神病史和对艾滋病毒有重要意义的病史,因未能茁壮成长和担心丈夫遗弃和与孩子分离的奇怪行为而被承认。精神病评估后,确定她没有独立照顾自己的能力;然后寻求成人保护服务并获得监护权。虽然承认,病人一再拒绝治疗,放置了一根用于强制营养和药物治疗的喂食管(尽管她曾一度自己取出了这根管子),并接受了两次电惊厥治疗(ECT)。此后不久,病人的法庭指定的监护人会见了初级医疗,精神病学,和道德团队讨论在复杂的社会和文化需求背景下的护理目标。集体确定患者选择拒绝护理(包括营养,实验室工作,药物,和ECT)和一些重复的行为(例如,否认离婚,否认艾滋病毒,在导致住院的急性应激源的背景下,可以认为拒绝治疗)在文化上是适当的。所有团队都得出结论,因此,患者有能力拒绝这些干预措施,并且进一步的强制干预比改善结局更有可能加剧已经很重要的创伤史.最终,病人能够出院,由她的监护人照顾,她将帮助她获得社区成员的支持,这些成员分享她的语言和文化。
AbstractA 29-year-old female East African refugee with no formal psychiatric history and a medical history significant for HIV was admitted for failure to thrive and concern for bizarre behavior in the context of abandonment by her husband and separation from her child. After psychiatric evaluation, it was determined that she did not have the capacity to care for herself independently; adult protective services then pursued and was awarded guardianship. While admitted, the patient repeatedly refused medical treatment, had a feeding tube placed for forced nutrition and medications (though she did at one point remove this tube herself), and received two electroconvulsive therapy (ECT) treatments. Soon thereafter, the patient\'s court-appointed guardian met with the primary medical, psychiatric, and ethics teams to discuss goals of care in the setting of complex social and cultural needs. It was collectively determined that the patient\'s choices to refuse care (including nutrition, lab work, medications, and ECT) and some repeated behaviors (e.g., denial of divorce, denial of HIV, denial of need for care) could be considered culturally appropriate in the context of the acute stressors leading up to hospitalizations. All teams concluded, therefore, that the patient had the capacity to refuse these interventions and that further forced intervention would pose a greater chance of exacerbating her already-significant trauma history than improving her outcomes. Ultimately, the patient was able to be discharged into the care of her guardian, who would assist her in receiving support from members of her community who share her language and culture.