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Case Report: Decision-Making Capacity and Religious Conversion - A case of Dialysis Refusal
By Dinesh Mittal MD, Samuel F. Sears Jr. PhD, Phillip R. Godding PhD, and Marti D. Reynolds MDiv
From Annals of Long-Term Care, August 1999;7[8]:320-322


Abstract
The authors describe a case of the clinical and ethical management of a patient presenting with a recent religious conversion and his subsequent noncompliance with hemodialysis. Working within the patient’s belief system, rather than contesting it, and maintaining a therapeutic alliance with the patient were critical in achieving resolution between the patient’s reality and an effective medical intervention.

    Dr. Mittal, Dr. Godding, and Rev. Reynolds are with the Department of Veterans Affairs Medical Center, Jackson, MS. Dr. Mittal is also Assistant Professor of Psychiatry, University of Mississippi Medical Center, Jackson. Dr. Sears is with the University of Florida, Department of Clinical and Health Psychology, Gainesville, Fl. Address for correspondence: Dinesh Mittal, MD, Department of Veterans Affairs Medical Center, Psychiatry Service 116A, 1500 E Woodrow Wilson Dr, Jackson, MS 39216.


Assessment of decision-making capacity generally establishes that the patient understands relevant information about the issues at hand, reflects on the options according to his or her values, and adequately communicates his or her choices. [1,2] Many factors influence capacity, including psychiatric disorders, personality, and personal beliefs and values. Religious beliefs can dramatically affect decisions about various medical procedures and treatments (e.g., Jehovah’s Witnesses and blood transfusion). However, in most cases, it does not impact capacity or adherence to the medical regimen. The authors describe a case of the clinical and ethical management of a patient who recently converted and his subsequence noncompliance with hemodialysis.

Case Presentation
The patient is a 55-year-old married male with end-stage renal disease who receives chronic hemodialysis in a nursing home. He was referred to psychiatry for evaluation of his refusal of further hemodialysis. He reported that he had experienced a religious conversion two weeks before, which no longer allowed him to use dialysis or medication. Staff members had noted no previous episodes of such non adherence.

The patient also had hypertension, diabetes mellitus, hypothyroidism, a below-the-knee amputation, and post traumatic stress disorder related to combat during the Vietnam War. He was estranged from his wife and family, and he refused to grant permission to contact them. His medications included sertraline, trazodone, clonidine, diltiazem, levothyroxine, cisapride, and omeprazole.

During his religious conversion, the patient reported to the medical staff that he experiences ‘“salvation” and “healing” and was currently in the presence of God. He described an out-of-body experience - viewing his body on the bed while he sat in a wheelchair. The patient called a friend who shared his religious beliefs, and he exhibited glossolalia (speaking in tongues), engaged in prayer, and reported that he had conquered “the evil”. After religious conversion, he watched religious television shows, read scriptures, and prayed frequently. He reported that he was not a member of any organized religion.

At the time of consultation, the patient denied depressive symptoms, including suicidal ideation or intent. No psychosocial precipitants of depression were identified. On examination, he was alert, oriented, and kempt. His mood and affect were euthymic and appropriate. His speech was fluent and without pressure or increased amount. There was no evidence of formal thought disorder, hallucinations, or delusions. His memory, concentration, and abstraction were intact.

The patient demonstrated a good understanding of his physical and psychiatric problems and the consequences of treatment refusal, including death. His judgment was considered questionable, however, as indicated by his refusal to continue lifesaving dialysis. He told staff members that his spiritual healing was more important than his physical healing, and that any treatment would contradict his newfound faith. He vehemently denied that refusal of dialysis was a passive suicidal behavior.

The patient’s refusal of dialysis appeared influenced solely by his religious conversion. The metabolic parameters did not show any shift from the usual range, and his clinical presentation was unchanged except for the religious ideation.

A chaplain service consult revealed that his religious beliefs were largely consistent with local religious ideas. After receiving this information, the authors considered the patient’s religiosity to be non delusional and not the result of a mental disorder. The authors deemed the patient to have the capacity to refuse dialysis in a manner consistent with his own religious reality. An ethics advisory committee consisting of a patient representative, an administrative staff member, a chaplain, a social worker, a nurse, a psychologist, and a physician agreed with this assessment.

In summary, a psychiatry consultation with significant religious components evaluated capacity in this case through the following methods:
  • Employment of multidisciplinary evaluations (i.e., psychiatrist, psychologist, social worker, and clergy) to assess physical and psychological suffering.
  • Consideration of the individual’s religious perspective, by including the patient’s own teacher of faith in the therapeutic alliance
  • Consultation with the ethics advisory board because of the life=threatening consequences of treatment refusal (the authors would have included family members in the evaluation process, but because the patient declined to consent for contact with the family, they honored his wishes and upheld confidentiality)
The attending physician, clergy, and consultation psychiatrist continued to meet with the patient daily. He experienced severe nausea and vomiting consistent with uremic syndrome after approximately 72 hours. As his condition worsened, he indicated to the staff that perhaps God had “healed” him spiritually rather than physically and that dialysis was still necessary. Dialysis was resumed the following day, and the patient agreed to brain imaging to rule out a cardiovascular accident. An electroencephalogram was noncontributory.

Discussion
This case highlights the difficulties presented by refusal of medical treatment due to religious conversion and subsequent refusal of lifesaving treatment. The authors felt professionally, ethically, and morally responsible to strike a balance between “patient autonomy” and “paternalism”, as reflected in Jackson and Younger’s [3] words: “Living up to this sense of responsibility can only enhance the true autonomy and dignity of our patients.” In such cases, allowing the patient to refuse treatment that may accelerate the dying process represents a professional crisis for the primary physician.[4] Although the main responsibility for deciding whether to hasten death rests with the primary physician, both the primary physician and the psychiatrist who evaluates the patient share the moral responsibility and the emotional burden of decision making.[5]

The authors applied the highest test of capacity and investigated possible psychiatric and general medical conditions that may have influenced the patient’s judgment. In the absence of any identifiable disorder influencing his choice, they considered him capable and felt ethically and morally bound to allow him to choose death while respecting his autonomy and religious freedom. The employment of multidisciplinary teams provided additional professional expertise necessary to fully evaluate the patient’s capacity and to exercise sound clinical judgment.

Despite the patient’s termination of dialysis, the treatment team remained actively involved with him. This strategy may have allowed the patient to resume dialysis and reinterpret his conversion in a spiritual manner rather than in physical terms.

As a result of the prevalence of religious beliefs in medical patients,[6,7] health professionals are likely to encounter conflicts between longstanding religious beliefs and some medical decisions. This case was unusual because abrupt changes in religious beliefs affected treatment. In this situation, the authors found that working within the patient’s belief system, rather than contesting it, and maintaining a therapeutic alliance with the patient were critical in achieving resolution between the patient’s reality and the most effective medical intervention.

References
1. Applebaum PS, Grisso T. Assessing patient’s capacity to consent to treatment. N Engl J Med 1998;30:296-299.
2. Schindler BA, Ramchandoni D, Matthews MK, et al. Competency and the frontal lobe. Psychosomatics 1995;36:400-403.
3. Jackson DL, Younger S. Patient autonomy and “death with dignity”: Some clinical caveats. N Engl J Med 1979;301:404-408.
4. Block SD, Billing JA. Patient requests to hasten death: Evaluation and management in terminal care. Arch intern Med 1994;154:2039-2047.
5. Block SD, Billings JA. Patient requests for euthanasia and assisted suicide in terminal illness. Psychosomatics 1995;36[5]:445-457.
6. Bearon LB, Koenig HG. Religious cognitions and the use of prayer in health and illness. Gerontologist 1990;30[2]:249-253.
7. Sears SF, Greene AF. Religious coping and the threat of heart transplantation. Journal of Religion and Health 1994;33:221-229.


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