Risk-Benefit Evaluation for Surgery in a Patient with Psychiatric Complications

摘要

Our patient was a 56-year-old woman with bipolar disorderand chronic obstructive pulmonary disease who continuedto smoke, and who presented to the ER with intermittentsubsternal chest pain. In the last year, she had had severalsimilar episodes, with multiple presentations to the ED.Each time, she refused further evaluation and left the hospitalagainst medical advice, reportedly “to smoke cigarettes.”At this visit an electrocardiogram revealed an inferiornon-ST elevation myocardial infarction. She was admitted tothe CCU for cardiac angiography, which revealed multi-vesselcoronary artery disease. The cardiologists recommendedcoronary artery bypass graft (CABG) surgery.During medical rounds, the cardiology team presented theresults of the angiogram and treatment recommendations tothe patient and her boyfriend. The team also discussed therisks and benefits of the CABG procedure, including medicationsthe patient would start and continue daily, suchas dual antiplatelet therapy and other important medications.She also declined nicotine replacement therapy, whilebecoming aggressive towards medical staff because she wasnot allowed to leave the hospital to smoke.As she became increasingly agitated, she stated she wasnot reliable enough to take the daily medications after surgeryand refused the surgery until she could go outside tosmoke. Her agitation escalated into violent behavior towardsstaff and she began pulling out her intravenous lines. Inresponse, the cardiac team called hospital security as well asa psychiatric consult to evaluate her capacity. The psychiatricteam determined that she lacked capacity to make medicaldecisions due to her agitation, inability to make rationaldecisions, and behaviors that necessitated sedation. Whileshe was sedated, discussions with her family revealed theiranxiety about her prognosis and their strong desire for her toundergo CABG.