general hospital psychiatry – Go Retire Psychiatrist

I just found a blog post I wrote about assessing decisional capacity. It’s over 13 years old and you can tell I was a little frustrated when I wrote it. It was back in the days when consulting psychiatrists were called psychosomatic medicine specialists. Here’s to another blast from the past.

Blog from 2011: Thoughts on Assessment of Medical Decision-Making Capacity

Listen very carefully to what I’m about to say. A patient’s ability to make decisions about her medical or surgical treatment does not depend on knowing her surgeon’s name.

Let me put it differently. Simply because you can recall your surgeon’s name doesn’t mean you have the decisional capacity to give or not give informed consent to have surgery.

If that’s too obvious to most of you, then maybe I can stop worrying that it isn’t to so many doctors, who sometimes misunderstand or are simply unaware of the basic principles of assessing decisional capacity regarding medical treatment. Believe it or not, some physicians actually believe the above is part of an adequate decisional capacity assessment.

Psychosomaticists are frequently called to assess decisional capacity to participate in the informed consent discussions that are such an important part of the doctor-patient relationship today. Many non-psychiatric doctors simply don’t feel confident that they can do it themselves. And when they try, their description of the process often indicates an alarming deficit in their medical school education about this basic skill.

In order to give informed consent, you need to have enough information from your doctor, be able to voluntarily make a decision without undue pressure from others (including your doctors), and be competent to decide. Exceptions to obtaining informed consent include but are not limited to “incompetence” (the inability to decide) and medical emergencies.

In a nutshell, the basic elements of assessing decisional capacity are:

Any physician can do it; a psychiatric consultation is not obligatory though it may be helpful in difficult cases in which delirium or other mental illness may be substantially interfering with decision-making.
The patient’s ability to understand her medical condition and the risks and benefits of the main and alternative medical interventions proposed as treatment.
The patient’s appreciation of the nature of her medical condition and the potential consequences of the treatment options or no treatment in the context of her values and wishes.
The patient’s ability to reason through her choices regarding treatment.
The patient’s ability to express a choice.

Notice that nowhere in the above list is recall of the surgeon’s name even mentioned. Remembering your surgeon’s name may be flattering but it’s not essential to the assessment of decisional capacity.

There are several reasons to assess decisional capacity including but not limited to an abrupt change in the patient’s mental status. This is commonly caused by delirium, which by definition is an abrupt change in affect, cognition, and behavior that fluctuates and is by definition related to medical causes.

Any physician can conduct a decisional capacity evaluation, yet a psychiatric evaluation is frequently requested. The reason for that may arise from the assumption that the Psychosomaticist is a sort of “informed consent technician”[1]:

“Efficiency model” scenario
1. Incompetence is presumed.
1. Psychiatric consultant is expected to remove legal barriers expeditiously to obtain a surrogate decision maker.
“Pseudoconsultation” scenario
1. Consultation requestor lacks the patience, interest, or time to do an assessment.
“Persuasion” scenario
1. Psychiatric consultant is expected to persuade the patient to reverse his refusal of needed treatment.
“Protection” scenario
1. Psychiatric consultant is expected to provide documentation to protect against potential litigation.
“Punishment” scenario
1. Stigma associated with psychiatric evaluation is used unconsciously to punish treatment refusal behavior.

In all fairness, psychiatrists are sometimes just as guilty of this buck-passing; for example, when we request a cardiology consultation to “medically clear” a patient for electroconvulsive therapy to treat life-threatening depression.

In an ideal world, a decisional capacity evaluation would be requested in and accepted in “the true spirit of dialogue as the result of a genuine evaluation of the patient’s mental state as a whole”[1].

We don’t live in an ideal world. So when a doctor is truly stuck and needs help with decisional capacity evaluations, she can confidently call a practical Psychosomaticist in the true spirit of collaboration as a result of the genuine appreciation of the importance of the patient’s medical and psychiatric care as a whole.

1. Zaubler, T.S., M. Viederman, and J.J. Fins, Ethical, legal, and psychiatric issues in capacity, competency, and informed consent: an annotated bibliography. Gen Hosp Psychiatry, 1996. 18(3): p. 155-72.

I’m back in the saddle again after a brief hiatus according to the terms of my phased retirement contract. During my time away, I thought about what a short introduction to Consultation-Liaison (C-L) Psychiatry might include to give medical students and other trainees a snapshot look at what CL psychiatrists encounter in their work in a busy general hospital.

As I considered what to include, it occurred to me that common consult questions typically could be classified into three basic groups:

Manage Crises: This often involves assessment of medically ill patients for whom there are concerns about suicide or violence toward others, including health care professionals.

Manage Medications: Frequently, I get questions about how to manage psychiatric medications, often in patients who are being treated with multiple medications; or need authorization for clozapine (an atypical antipsychotic which usually must be authorized initially by a psychiatrist); or need adjustment of medications in the setting of medical problems like cardiac disease or bowel resection (in which absorption might be affected).

Manage Behavior: This doesn’t always involve violent behavior but may include challenging and potentially disruptive acting out in the setting of delirium, or associated with patients who might have personality disorders or abnormal illness affirming disorders.

These broad categories make up the biggest share of the concerns my colleagues in general medicine hospitalists and surgery have about a significant proportion of patients in a large hospital.