Abstracts
Résumé
Contexte : En psychiatrie, la question d’offrir des soins palliatifs et de fin de vie pour ce qui serait une « condition psychiatrique terminale » ou, plus globalement, de considérer adopter une approche palliative pour des problèmes de santé mentale sévères et persistants constitue encore un tabou. Méthodologie : Cette question est abordée par l’analyse d’un cas effectuée lors d’une consultation en éthique clinique à l’aide de la méthode des scénarios d’Hubert Doucet. Il s’agit de madame Sanchez, une patiente âgée de plus de 90 ans, présentant des troubles psychiatriques, exprimant le désir de mourir par des gestes suicidaires, refusant les traitements proposés, ainsi que refusant de boire et manger. Son histoire clinique est racontée par le filtre de l’accompagnement réflexif offert en éthique clinique aux diverses parties prenantes. Résultats : L’analyse de cas, loin de répondre aux défis posés par le concept des soins palliatifs et de fin de vie en contexte psychiatrique, présente néanmoins une occasion d’en nommer les enjeux éthiques principaux : la souffrance psychique, le refus de manger et de boire ainsi que le refus de traitement, la sédation palliative et l’aide médicale à mourir, les volontés et directives médicales anticipées, ainsi que les défis clinico-organisationnels suscités par la clientèle gérontopsychiatrique. Conclusion : Les défis cliniques et éthiques demeurent nombreux pour les professionnels et les décideurs afin de répondre aux besoins de la clientèle de santé mentale très âgée. Nous appelons à un plus grand développement des connaissances sur ce thème précis.
Mots-clés :
- psychiatrie,
- soins palliatifs et de fin de vie,
- refus de boire et de manger,
- refus de traitement,
- éthique,
- idéation suicidaire,
- désir de mourir,
- personnes âgées
Abstract
Background: In psychiatry, the issue of providing palliative and end-of-life care for what would be a “terminal psychiatric condition” or considering a palliative approach to severe and persistent mental health problems is still a taboo. Methodology: This question is addressed through an analysis of a case arising during a clinical ethics consultation, using Hubert Doucet’s scenario method. It is about Mrs. Sanchez, a patient over 90 years of age with a psychiatric profile, expressing the desire to die by suicidal gestures, refusing the proposed treatments, and refusing as well to drink and eat. Her clinical history is told through the filter of reflexive support offered in clinical ethics to the various stakeholders. Results: The case analysis, far from responding to the challenges posed by the concept of palliative and end-of-life care in a psychiatric context, nevertheless presents an opportunity to name its main ethical issues: psychic suffering, refusal to eat and drinking as well as refusal of treatment, palliative sedation and medical assistance in dying, wishes and advanced medical directives and clinical-organizational challenges for geriatric psychiatry clients. Conclusion: There are still many challenges for professionals and decision-makers to meet the needs of older mental health clients. We call for further development of knowledge on this specific topic.
Keywords:
- psychiatry,
- palliative and end-of-life care,
- refusal to drink and eat,
- treatment refusal,
- ethics,
- suicidal ideation,
- wish to die,
- elderly
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Appendices
Remerciements / Acknowledgements
Les auteurs remercient chaleureusement les personnes qui ont accepté de relire le manuscrit et de nous faire part de leurs généreux commentaires. Il s’agit des psychiatres Dre Marie-Luce Quintal et Dre Julie Séguin, de Michel Lorange, éthicien clinique au Centre d’éthique du CISSS de Laval et de Yanick Farmer, professeur d’éthique de la communication à l’UQAM. Les auteurs ont obtenu le consentement du fils pour raconter l’histoire de Madame Sanchez. Nous lui en sommes très reconnaissants.
The authors would like to thank those who agreed to review the manuscript and provide us with their generous comments. They are the psychiatrists Dr. Marie-Luce Quintal and Dr. Julie Séguin, Michel Lorange, clinical ethicist at the Centre d’éthique du CISSS de Laval and Yanick Farmer, professor of communication ethics at UQAM. The authors obtained the son’s consent to tell the story of Madame Sanchez. We are very grateful to him.
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