Module 2 – Respecting Patient Rights
Ethics Case 2.3
Psychosis, Side-Effects, & Surrogate Decision-Making
Mr. McQueen, a 32-year-old man with a diagnosis of schizophrenia eight years ago, has been successfully managing his condition for the past five years without medications. This was following a severe reaction to his antipsychotic medications six years ago that resulted in tardive dyskinesia, a condition involving involuntary facial movements, as well as significant rapid weight gain. These deeply affected his self-esteem, professional confidence, and made him pre-diabetic. Mr. McQueen worked closely with his psychiatric team to gradually reduce and eventually discontinue his antipsychotic medications. This decision was made collaboratively with his psychiatrist, Dr. Rice, his mother (a retired nurse), and his wife whom he married two years ago.
During his medication-free period, Mr. McQueen had been thriving in many aspects of his life. He secured steady employment as a graphic designer, something he attributed to his increased creativity and mental clarity without the cognitive dulling effects of his previous medications. While he occasionally experienced mild auditory hallucinations and some disorganized thinking, these symptoms were manageable through weekly therapy sessions, mindfulness practices, and a strong support network. Mr. McQueen had been particularly vocal about his desire to remain medication-free, often stating, “I finally feel like myself again. I’d rather deal with some symptoms than lose who I am to those drugs.”
However, three weeks ago, Mr. McQueen’s condition deteriorated rapidly following a stressful period at work involving multiple tight deadlines and a difficult client relationship. He began experiencing severe paranoid delusions, believing that his coworkers were conspiring to steal his designs and sabotage his career. The situation escalated when Mr. McQueen confronted his supervisor aggressively, accusing the entire office of being part of an elaborate scheme against him. After he barricaded himself in the office bathroom for four hours, refusing to come out and making threats toward imagined persecutors, emergency services were called and he was involuntarily committed to the psychiatric unit.
Upon admission, the treatment team, aware of Mr. McQueen’s strong preference to avoid antipsychotic medications, attempted to manage his symptoms through environmental modifications, de-escalation techniques, and intensive therapeutic interventions. However, after nearly three weeks of hospitalization, Mr. McQueen’s condition has not meaningfully improved. He remains deeply paranoid, refuses most meals believing the food is contaminated, and has become increasingly agitated, sometimes requiring security interventions when he attempts to “escape” what he perceives as a hostile facility.
A disagreement over treatment has created a significant rift between Mr. McQueen’s mother and his wife. His wife has become increasingly distressed watching her husband’s deterioration and thinks they should try him on medication. “This isn’t the man I married,” she tells the treatment team. “My husband is brilliant, kind, and capable. What I see now isn’t him, it’s his illness. He trusted me to make good decisions for him, and I believe if he could think clearly, he would want us to get him stable with the medication so that he can come home and get back to his life.”
However, his mother takes a different stance. Having witnessed her son’s previous struggles with medication side effects and remembering his distress over the tardive dyskinesia, she firmly believes they should honor his previously expressed wishes. “My son was very clear about this,” she argues. “He said he would rather live with symptoms than go back on those medications. As his mother, I’ve seen him struggle with his illness and the treatments. He was doing well before this episode, and he can get well again without medications if we give him time and support.”
The conflict has intensified during family meetings. The primary psychiatric nurse, Nurse White, has expressed concern about the prolonged hospitalization and Mr. McQueen’s decreased quality of life. “We’re going on three weeks now, and Mr. McQueen is suffering,” he explains. “He’s lost fifteen pounds, barely sleeps, and spends most of his day in a state of terror. The other patients are also affected when he’s had aggressive outbursts, traumatizing some of our more vulnerable residents. From a clinical standpoint, this level of sustained psychosis without intervention raises serious questions about our duty to relieve suffering.”
Dr. Rice acknowledges the complexity of the situation. “I’ve known Mr. McQueen for years, and I understand his fears about medication. But I’m also watching him deteriorate in ways that could have lasting consequences. The longer someone remains in an acute psychotic state, the more difficult recovery becomes. And instead of long-term medication, we could also consider trying a short course of medication to stabilize him and perhaps allow him to give some input on his care.”
His wife agrees with this, saying “Look at him, he thinks he’s in some conspiracy. This isn’t about convenience or making our lives easier, it’s about getting him back. He worked so hard to build a life, a career, a marriage. Every day we wait, that life slips further away.” However, his mother remains resolute, responding that “he was adamant that he didn’t want to be that person who was controlled by medications that made him sick in other ways. He said he’d rather take the risks that come with his mental illness than face the horrible side-effects that came with treatment.”
The treatment team has discovered that under state law, there is no clear hierarchy established for surrogate decision-making in cases of psychiatric treatment when family members disagree. The clinical ethics committee has been consulted to help determine who should be designated as Mr. McQueen’s surrogate decision-maker and to offer guidance on how best to proceed.
