L’étude des comorbidités, des facteurs de risque de pathologies organiques ou de la baisse de l’espérance de vie des patients atteints de pathologies mentales, notamment psychotiques, fait l’objet de nombreuses publications. La prise en charge, l’accompagnement, notamment en soins palliatifs, de ces patients, mais également le vécu tant des patients que des soignants dans ce type de situation sont plus rarement abordés. À partir de l’histoire de Pierre, patient suivi pour une schizophrénie paranoïde et atteint d’un cancer du poumon au pronostic létal à court terme, nous évoquons l’accompagnement, la prise en charge de ces patients dans le cadre de soins palliatifs en secteur spécialisé psychiatrique et la complexité que cela peut représenter, tant pour les patients que pour les équipes soignantes. Ainsi, le lieu de prise en charge mais également l’évaluation du comportement ou de la douleur s’avèrent à l’origine de réflexions complexes que nous discutons. Nous initions par la suite une réflexion autour des enjeux de cet accompagnement singulier avec les notions de travail du trépas et, plus généralement, des enjeux légaux et éthiques autour des refus de traitements dans ce cadre précis.

The studies of comorbidities, risk factors of organic pathologies, or declining life expectancy of patients with mental disorders, particularly psychotic disorders, are the subject of many publications. The cares, including palliative care, for these patients, but also the patients and caregivers experience in these situations are rarely described in the literature. From the story of Peter, we evoke the palliative support and the management of these patients in a psychiatric hospital.

Pierre was monitored for paranoid schizophrenia. He was hospitalized in a psychiatric hospital after a suicidal attempt. Before that event, he spent a large part of his life in the psychiatric hospital, with more than 50 hospitalisations. After 1 month of hospitalisation, a diagnosis of a lung cancer with lethal prognosis was done. Pierre was very anxious, especially about the medical exams, and also the chemotherapy. He did not eat and sleep anymore. He told every doctor and nurse that he did not want any treatment, especially not chemotherapy. After discussions with Pierre, his family, specialized doctors in pneumology and palliative care, we decided to respect his will, and Pierre was informed about that decision. After that, he felt relieved, ate and slept again, and kept his normal activities in the hospital. Pierre died 4 months after the diagnosis was done.

We present a brief introduction on palliative care history in France, and discuss the specificities of this kind of monitoring, especially about the management of the medical teams, but also the assessments of the behavior or the pain. It is sometime really difficult to assess behavior and pain for patients suffering from schizophrenia. These patients cannot talk about their pain as well as other patients because of the language impairment and lack of capacity of expressing their feelings. Also, it seems, in recent research, that schizophrenic patients do not feel the pain as other patients. These specificities increasingly complex the evaluation, at the limit of normal and pathologic event. Beyond these practical aspects, we initiate a reflection on the challenges of this unusual support. In fact, we discuss the end of life and the specific follow-up of this patient, and the legal aspects in this situation of patients suffering from severe psychiatric illness. We also talk about the impact of this kind of management on the patient and the medical team. We question and discuss the possibility of patients suffering from severe schizophrenia to take some decisions about their health. Finally, we question ethical aspects in this specific context, dealing with unreasonable obstinacy, refusal of treatment. In fact, it is an ethical question to know if we have to consider the will of a patient suffering from judgment trouble because of his psychiatric disease if he do not want a medical treatment. Do we have to respect that choice? Do we have to try to convince him, even if he will have some psychotic anxiety?

We discuss in this publication the care for patient suffering from psychosis disorders, concerning the patient's right, but also our responsibility as doctors in medical decision. In the situation described, limiting curative care was adapted to the gravity of the disease, and did not compromised the patient's integrity. The patient's right and responsibility needs to be treated for each situation, without any theorical previous rules, except the Leonetti law. We argue that caregivers in psychiatric hospital have to accompany these patients, also at the end of their lives. Some teams in psychiatric hospital works for the prevention and treatment for the physical pain, and we probably need to extend their abilities to healthcare at the end of life, promoting medical education.