Competency issues in referrals to a consultation-liaison service

Convening Expert Panels to Identify Mental Capacity Assessment Items

The objective of this study was to attempt to develop an index of assessment items important to most, if not all, mental capacity determinations. A group process, judgmental method was used. Three separate panels of multidisciplinary experts were assembled to define relevant assessment items and to assign importance weights to the items. All three panels generated a list of assessment items, but panelists refused to assign importance weights. Four items were identified by all three panels, six were identified by two panels, and three were identified by one panel only. A composite list of mental capacity assessment items was generated, but the study failed to generate a standardized assessment instrument.

Competency and the Capacity to Make Treatment Decisions: A Primer for Primary Care Physicians

Common law dictates that individuals possess autonomy and self-determination, which encompass the right to accept or refuse medical treatment. Management of medical treatment can be complicated in situations when the ability of the patient to make reasonable decisions is called into question. Our legal system endorses the principle that all persons are competent to make reasoned decisions unless demonstrated to be otherwise. This review will discuss the standards upon which capacity and competency assessments are made. Practical suggestions are offered for clinicians to employ in patient interviews conducted to assess capacity. Issues related to advance directives, surrogate decision making, guardianship, and implied consent are also discussed. The role psychiatric consultants take in capacity assessment can assist the primary care physician confronting the complexities encountered when attempting to treat the incapacitated or incompetent patient.

Competency evaluations on the consultation-liaison service. Some overt and covert aspects

Competency assessments are a growing function of the consultation-liaison (C-L) psychiatrist. Such consultation requests often mask a variety of psychosocial issues that are a source of frustration to the referring physician responding to the pressures of the changing health care delivery system in the acute care setting. This study identifies the issues and the outcome of psychiatric consultation in these patients. The implications of this burgeoning role for the C-L psychiatrist are also explored.

A noncompliant patient with fluctuating capacity

Because of intermittent refusal of both dialysis and medications, serial capacity assessments were made on a 38-year-old male on hemodialysis and receiving TB treatment. His capacity to make an informed treatment decision appeared to fluctuate and despite multidisciplinary involvement and a court determination that treatment should take place, questions remained as to how such a case should be managed in the patient's best interest. The process of making a capacity determination was reviewed from both a psychiatric and legal viewpoint and alternative strategies presented.

A prospective multicenter study of competency evaluations by psychiatric consultation services

Psychiatric consultation for assessment of competency is common but infrequently studied. Past studies have used chart reviews. The authors prospectively studied 88 consecutive psychiatric consultations at 3 centers. Competency evaluation was performed to determine whether the patient could 1) sign out of the hospital against medical advice (AMA) (N = 16); 2) give informed consent (N = 16); 3) take care of him-/herself (N = 33); 4) refuse medical care (N = 24); or 5) deal with other matters (N = 12). Patients with a favorable risk-benefit ratio were more likely to be seen in consultation compared with those with an unfavorable ratio. Patients in whom there was concordance in the assessment of the psychiatric consultant and the referring physician (N = 61) were more likely to be male, single, to have psychotropics recommended, to sign out AMA, and to be discharged from the hospital. Patients in whom there was disagreement between the consultee and the consultant merits further study.

Evaluations of competency of patients with organic mental disorder

The authors retrospectively reviewed the charts of all patients (N = 903) seen by the Psychiatric Consultation Service from January 1, 1989 through December 31, 1991. A total of 74 patients had a diagnosis of organic mental disorders (delirium, dementia, or both). Of these, 32 patients were evaluated for competency (Study group), while the remaining 42 were evaluated for reasons other than competency (Comparison group). Patients in the Study group were more likely to be African American and less likely to be prescribed psychotropic drugs than the Comparison group. The majority of patients with organic mental disorder (87.5%) evaluated for competency were judged to be incompetent.

Psychiatric consultation for competency to refuse medical treatment. A retrospective study of patient characteristics and outcome

Forty-one psychiatric consultations on medical-surgical inpatients for competency to refuse medical treatment were studied retrospectively. The competent (n = 16) and incompetent (n = 25) patients were compared in terms of demographic data, diagnoses, clinical variables, details about treatment refusal, and outcome following competency assessment. The incompetent patients tended to be men, the focus of more urgent requests, and to have refused operations. The incompetent patients tended to have organic brain syndromes; the competent patients had personality disorders, adjustment disorders, or no psychiatric diagnosis. Ultimate acceptance of treatment initially refused was common in both groups; differential psychiatric interventions were recommended. The process of psychiatric consultation appeared to facilitate acceptance of treatment initially refused.

Competency evaluations in a VA hospital. A 10-year perspective

The authors reviewed all 228 competency evaluations performed at the Baltimore VA Medical Center during a 10-year period. Between 1980 and 1984 and 1985 and 1989, the rate of inpatients who had competency evaluations increased from 0.20% to 0.42%, and the average number of competency evaluations per year doubled from 12 to 24.6. The percentage of all psychiatric consultations which were for competency evaluation nearly doubled from 5% to 9.4%. The rate of competency evaluations was slightly but not significantly higher for patients over age 65 than the rate for younger patients (0.44% vs. 0.33%). However, older patients were significantly more likely to be judged incompetent.

Reducing unnecessary psychiatric consultations for informed consent by liaison with administration

The frequency of a psychiatric consultation being requested to assess a patients' capacity to give informed consent varies among institutions, with most recent surveys reporting a frequency of between 3% and 8% of all consultations. At Montefiore Medical Center, a hospital policy was interpreted as mandating such consultations for all patients with possible or even definite lack of decisional capacity. From 1987 to 1988, 55% of all psychiatric consultations in the institution were for consent. Only 9% of the consent patients seen had an Axis I diagnosis other than organic mental syndrome (OMS). Because many of these consultations were believed to be unnecessary, with patient clearly able or unable to give consent, the consultation service worked first with administration to modify the guidelines, and then educated the medical and nursing staff as to when consultation was indicated. With this program, the number of consent consultations fell from 958 in 1988 to 177 in 1990, representing a major saving of staff time and third-party billings. In this era of cost containment and outside review of professional practices, psychiatrists must take responsibility for identifying areas where patient services and billings for them are not justified by clinical indications.

Reasons for requests for evaluation of competency in a municipal general hospital

During the period from July through September 1989, 380 referrals to a psychiatry consultation-liaison service were reviewed. Of these patients, 25% were referred for a determination of competency, despite the fact that they often showed no evidence of mental illness. Seventy-five percent of the patients were found to be competent. Fear of medical legal consequences, physician's anxiety, lack of understanding of the rights of patients to refuse treatment, and a misunderstanding of the physician's duty when presented with such refusal seem to be the reasons for the large number of referrals.

Informed consent, competency, and the illusion of rationality

Since the advent of informed consent, patients have become more involved in treatment decisions than ever before. To give an informed consent or refusal a patient must be competent to understand the information being presented. Although most authors agree on the need for a structured format for assessing competency, in practice this step is often omitted if the patient's decision "makes sense." In this paper we present two cases in which acutely ill patients gave apparently rational refusals of potentially life-prolonging treatment. Following their recovery, both viewed their earlier decisions as irrational. These cases demonstrate some of the difficulties in assessing competency and rationality in gravely ill patients, and the need for careful evaluation regardless of the apparent rationality of expressed desires.

When do physicians request competency evaluations?

Fifty consecutive requests for competency evaluations were reviewed retrospectively to determine the characteristics of the request. The data from this study suggest that requests for competency are seen within certain discrete, demographically varied categories; are often urgent; are usually not the result of a functional Axis I disorder; are more common for patients with previously diagnosed organic mental disorders; are often stimulated by patients who do not participate in diagnostic or treatment plans or by patients who threaten to leave against medical advice; are less frequently concerned with informed consent; and are more common in younger patients. Overall, patients are as likely to be judged competent as incompetent. Elements of the mental status examination that are crucial to the assessment of competency are delineated.

Competency evaluations in a general hospital

This study describes 90 requests for competency evaluation received by a psychiatry consultation service between 1983 and 1986. Most of the requests were prompted by a patient's refusal to accept a physician's recommendations regarding treatment or disposition. Delirium and dementia accounted for the majority of diagnoses in the population deemed incompetent. Consultees were more likely to follow recommendations for further medical evaluation than to obtain recommended guardianships, living-skill assessments, or neuropsychometric testing. Guardianships were established for only seven of 26 patients deemed incompetent. This study demonstrates the need for consulting psychiatrists to be aware of the forensic issues of competency.

Geriatric and nongeriatric psychiatry consultation. A comparison study

Data from geriatric and nongeriatric psychiatry consultations done on medical and surgical inpatients at a Veterans Administration Medical Center over a 1-year period were analyzed. A total of 750 consultations were conducted. Patients age 60 and over were referred significantly more often for agitation and competency assessment, and significantly less often for suicidal ideation. More than half the older patients had evidence of an organic brain syndrome. Notably fewer geriatric than nongeriatric patients were diagnosed as having personality disorders. Psychotropic medications were prescribed and further medical workups were recommended more often for the elderly. The results have important implications for mental health professionals working with older patients. The need for more training of both psychiatric and nonpsychiatric residents in the management of geriatric patients is discussed.

Characteristics of patients referred to psychiatrists for competency evaluations

Requests for inpatient psychiatric consultations at a general hospital over a three-year period were reviewed. Of 2,423 referrals, 79 (3.3%) were specifically for evaluation of competency, and 78.5% of those cases resulted in a diagnosis of an organic mental disorder. The proportion of referrals with organic mental disorder was significantly greater than it was in a control population of patients referred for consultation for any reason. Patients with organic mental disorder who were referred for competency evaluation had greater cognitive impairment than did control subjects.

Dementia, mental retardation, and competency to make decisions

The psychiatric literature on competency indicates that a diagnosable psychiatric condition alone does not imply incompetency to make treatment decisions. Nonetheless, it is frequently assumed that individuals who are either mentally retarded or demented are incompetent to make decisions. The authors, focusing on the clinical assessment of judgment and decision making, describe two cases. In both, the patients' judgments were intact. The authors conclude: (1) Diagnosis is not the critical factor in determining competency. (2) The process of judgment and decision making has to be assessed on a case by case basis. (3) Further research is needed to develop clinical instruments to assess judgment.