Background: The study's main aim was to assess the end-of-life decision-making capacity and health-related values of older people with serious mental illness.Methods: A cross-sectional, observational study, was done at Weskoppies Psychiatric Hospital, Gauteng Province, South Africa that included 100 adults older than 60 years of age and diagnosed with serious mental illness. The Mini-Cog and a semi-structured clinical assessment of end-of-life decision-making capacity was done before a standardized interview, Assessment of Capacity to Consent to Treatment, was administered. This standardized instrument uses a hypothetical vignette to assess decision-making capacity and explores healthcare-related values.Results: The Assessment of Capacity to Consent to Treatment scores correlated (p < 0.001) with the outcomes of the semi-structured decision-making capacity evaluation. Significant correlations with impaired decision-making capacity included: lower scores on the Mini-Cog (p < 0.001); a duration of serious mental illness of 30–39 years (p = 0025); having a diagnosis of schizophrenia spectrum disorders (p = 0.0007); and being admitted involuntarily (p < 0.0001). A main finding was that 65% of participants had decision-making capacity for end-of-life decisions, were able to express their values and engage in advance care discussions.Discussion and Conclusion: Healthcare providers have a duty to initiate advance care discussions, optimize decision-making capacity, and protect autonomous decision-making. Many older patients with serious mental illness can engage in end-of-life discussions and can make autonomous decisions about preferred end-of-life care. Chronological age or diagnostic categories should never be used as reasons for discrimination, and older people with serious mental illness should receive end-of-life care in keeping with their preferences and values.
There are many complex concepts to consider during end-of-life discussions and advance care planning, especially when vulnerable populations such as older individuals with serious mental illness are involved. This article aims to summarize some of these important concepts, such as the effects of ageism, preservation of human rights and dignity, supported or shared decision making and palliative approaches. It emerged from a study that found two thirds of 100 participants 60 years of age and older with serious mental illness had end-of-life decision-making capacity. This finding highlighted the individual and contextual nature of decision-making capacity, the importance of consideration of individual values and protection of human dignity during end-of-life care. Healthcare providers have a duty to initiate end-of-life and advance care discussions, to optimize decision-making capacity, and to protect autonomous decision-making. Chronological age or diagnostic categories should never be used as reasons for discrimination and all patients should receive end-of-life care in keeping with their preferences and values.
Homicide-suicide (HS) has been defined as homicide committed by a person who subsequently commits suicide within one week of the homicide. In most cases it occurs within 24 hours. HS is a public health problem, victimising not only those directly involved in the act, but also family, friends, acquaintances, colleagues, witnesses and investigators. The literature and findings of recent South African research regarding HS are discussed to highlight the practical implications for risk reduction at primary care level and to address the provision of support services after HS cases. It has been consistently found that depressed men have the highest risk of committing HS, especially if they also abuse alcohol and have problematic personality traits/disorders, in the context of domestic violence or a problematic relationship. Delusional jealousy, although not a frequent finding, is a great risk for HS. The breakdown of an intimate relationship, with a recent or pending separation (real or imagined), has consistently been found to be the most common contributing factor to HS. Primary health care practitioners are likely to be the first contact that these individuals or families might have with the healthcare system. Through a better understanding of risk factors involved in HS, prevention may be enhanced in clinical practice. HS has far-reaching effects and healthcare practitioners can offer support and treatment to people traumatised by these events.
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