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Decision-Making in the Hospital Setting: Holds, Capacity, and Conservatorship. J. Jewel Shim, MD Director, Psychiatry Consultation and Liaison Service UCSF Medical Center. Objectives. Review psychiatric holds Differentiate between competence and capacity
J. Jewel Shim, MD
Director, Psychiatry Consultation and Liaison Service
UCSF Medical Center
What is the appropriate next step when a patient wants to leave AMA?a. Call securityb. Call the patient’s familyc. Call a psych consultd. Evaluate the patient’s capacity to determine his/her disposition
The following is true of capacity:a. A declaration that a patient lacks capacity is permanentb. An assessment of capacity covers all medical decisionsc. Demented patients by definition lack capacityd. If a patient lacks capacity in one area he/she lacks capacity in all areas
Ganzini et al., 2005
standards found in the law (Appelbaum and Grisso, 1988, 1995)
Pt is a 61 yo WM with h/o chronic schizophrenia self presented with 4 day h/o abd swelling and distention. During the course of his work-up, a large 10cm infrarenal AAA was discovered. Vascular consultation was requested, and pt was offered surgical intervention, which he refused. Psychiatry consultation was requested to evaluate pt’s capacity to refuse this procedure. On exam, pt was minimally interactive and lethargic, but consistently stated that he did not want the surgery. He was able to state understanding of his condition and that he might die if he did not have the surgery. However, when asked why he was declining the intervention, pt stated “I just don’t want it.” He was unable to elaborate despite many different approaches to clarify his reasoning across multiple visits. Pt repeatedly asked to go home. Because he was deemed a poor surgical candidate due to his endstage liver disease, the primary team (Medicine) felt that the patient should not have the surgery, and his wishes to go home should be honored.
Pt is a 66 yo DWF with h/o chronic schizophrenia, large uterine fibroids, and chronic vaginal bleeding adm from OSH for treatment of bilateral LE pressure necrosis ulcers. Pt had been found down in her trailer by her landlord after about 3 days. It was thought that pt, weak from blood loss from her fibroids, had fallen and was unable to get up. Pt consented to work-up and treatment for her LE ulcers but refused work-up for her uterine bleeding/mass. Psychiatric consultation was sought to evaluate capacity to refuse this work-up. On exam, pt continued to refuse work-up, and said that she does not have cancer, because “the voice of God” told her. She further stated that she does not believe in “allopathic medicine” and will treat the problem with her own homeopathic remedies. However, when asked why she is consenting to treatment for her LE ulcers, pt replied, “I would lose my legs.” She was unable to reconcile this contradictory statement with her refusal to consent to w/u for her uterine mass.
Patient autonomy Legal system
Pt is a 71 yo DAAM with DM2, CAD, CHF, HTN, chart h/o schizoaffective disorder/schizophrenia, long history of medication and f/u noncompliance, BIBA to ED with c/o CP. Pt has a h/o multiple presentations to the ED with similar sx and often refuses w/u and demands to leave AMA. As in the past, pt refused all attempts at work-up or physical exam and demanded food. Psychiatric consultation was requested to evaluate capacity to refuse work-up of acute CP. EMS Captain T, who is familiar with pt, stated that pt has been inadequately clothed (wearing hospital pajamas), eating out of garbage cans, and soiling himself on a regular basis. He recommended conservatorship. On exam, pt refused to discuss the elements of his current presentation or proposed treatment. He denied hallucinations, there was no evidence of thought disorder, and no delusional content was elicited. Per collateral, pt is not in psychiatric treatment but was conserved for 2 months one year ago. Pt however, eloped from the L-facility and conservatorship was not re-instated/further pursued.
Pt is a 55 yo AAF with h/o AF, DM2, stroke on coumadin, and chart h/o psychotic disorder who self presented with back pain, and found to have subtherapeutic INR. Pt was adm for adjustment of anticoagulation therapy. Pt has a h/o noncompliance with attending Coumadin clinic and with this medication. Psychiatric consultation was requested to conserve patient. Pt refused to be interviewed or discuss her care in any way.
59 yo WM with HCV cirrhosis, DM2, HTN, and chart h/o chronic paranoid schizophrenia self-presented with c/o abd, back, and eye pain with reduced visual acuity. Pt adm to Medicine for treatment of presumed SBP, ARF/CRF, and endophthalmitis. Pt however, refused paracentesis and intra-ophthalmic injection of abx. Treatment, though deemed to be urgent, was delayed in order to obtain psychiatric consultation to evaluate pt’s capacity to refuse these interventions. Pt able to discuss basics of his current medical conditions but unable to appreciate the consequences of his choice, nor able to discuss alternatives. He was unable to rationally explain his decision nor was he consistent in that he stated desire to get help for his conditions but refused to cooperate with proposed medical interventions.
Grisso and Appelbaum, 1998, Kopelman, 2007
Ms. P is an 85 yo WWF with h/o DAT, HTN, COPD and CAD. She was admitted with dehydration, ARF, and FTT. Pt lives alone, and it was determined that pt has not been eating or leaving her home because she believes her son has been poisoning her food and is trying to kill her. She has also stopped paying her bills, taking all of her money out of her bank account and hiding it under her mattress because she fears her son is also after her money. SW states “You have to conserve Ms. P.” Which type of conservatorship is most appropriate for Ms. P?a. Probate conservatorshipb. LPS conservatorship
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