Psychosomatics 39:55-60, February 1998
© 1998 The Academy of Psychosomatic Medine
A Prospective Multicenter Study of Competency Evaluations by Psychiatric Consultation Services
Prakash S. Masand, M.D.,
Anthony J. Bouckoms, M.D.,
Steven V. Fischel, M.D., Ph.D.,
Lori V. Calabrese, M.D., and
Theodore A. Stern, M.D.
Received January 30, 1997; revised March 7, 1997; accepted May 5, 1997. From the Department of Psychiatry, SUNY Health Science Center at Syracuse, Syracuse, New York; Hartford Hospital, Hartford, Baystate Medical Center, Springfield, MA; the Tufts University School of Medicine, Boston, MA; and the Massachusetts General Hospital, Boston, MA. Address reprint requests to Dr. Masand, Department of Psychiatry, SUNY Health Science Center at Syracuse, 750 East Adams Street, Syracuse, NY 13210.
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ABSTRACT
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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.
Key Words: Competency Evaluations • Patient Assessment • Consultation
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INTRODUCTION
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The assessment of competency poses a special challenge to psychiatrists, since it has important social, ethical, philosophical, and clinical implications. Although competency is a legal term and can only be determined by a judge, psychiatrists are often called upon to determine the psychiatric equivalence of competency for patients (for example, determination as to whether a patient has the capacity to understand the nature of a specific treatment or the consequences of lack of treatment).1, 2 Furthermore, the level of competency needed to make decisions may vary with the risk-benefit ratio.1 To our knowledge, this has never been tested empirically. Several retrospective studies have focused on the clinical and sociodemographic characteristics of the consultation request for competency evaluations.3–10 Up to 80% of patients evaluated for competency are diagnosed with organic mental disorders (OMD).11 However, retrospective studies, especially those lacking a control group, have inherent limitations. To our knowledge, only one small prospective study (N=15) has studied competency evaluations on a psychiatric consultation service.5
The purpose of our study, conducted in 1995, was to prospectively investigate more completely the criteria established by Roth et al.1 and the nature and outcome of competency evaluations performed by several psychiatric consultation services, as well as to further assess when physicians ask for consultations.
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METHODS
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The authors prospectively studied 88 consecutive consultations performed by the psychiatric consultation services at three centers: Massachusetts General Hospital, Hartford Hospital, and the State University of New York (SUNY) Health Science Center at Syracuse. For each consultation, the following information about each patient was recorded: age, gender, race, referring service, current psychiatric status, psychiatric history, family psychiatric history, history of substance or alcohol abuse or dependence, and date of consultation. The criteria of Roth et al.1 were used to classify patients, according to the risk-benefit ratio of their decisions (Table 5). The three groups of patients were compared by using the statistical program "Stat Plus." Chi-square tests and two-tailed t-tests were performed. Variables with P values  0.05 were considered significant.
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RESULTS
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The demographic characteristics and psychiatric history of our sample are shown in Table 1. The patients at Hartford Hospital were significantly younger than the patients at either the Massachusetts General Hospital or the SUNY Health Science Center at Syracuse. The patients at SUNY Health Science Center at Syracuse were more likely to be African American (P0.05) and less likely to be widowed (P0.05). The patients at Hartford Hospital were more likely to have a family history of psychiatric illness (P0.05) but not a personal history of psychiatric illness. The type and outcome of competency evaluation by the psychiatric consultant are shown in Table 2 and Table 3, respectively. Concordance between the consultee and the consultant and the risk-benefit ratio (by treatment and by site) are presented in Table 4, Table 5, and Table 6, respectively. By using the consultant's opinion as the "gold standard," we found the sensitivity and specificity to be 65.6% and 75.0%, respectively.
Table 7 and Table 8 show the differences between patients in the concordant and discordant groups. The demographic characteristics and psychiatric history are shown in Table 7. The discordant group had a significantly smaller number of patients (P0.05), and the patients who were were less likely to be single and more likely to have a college education (P0.05). As shown in Table 8, the patients in whom there was discordance were less likely to be seen for signing out against medical advice (AMA) (P0.05). Table 7 and Table 8 demonstrate that neither the psychiatric history nor the risk-benefit ratio group significantly affected the ability of the referring physician to accurately assess the competency of the patient.
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DISCUSSION
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To our knowledge, only one small study (N=15) has prospectively evaluated patients for competency in a general hospital setting.5 In that study, the age ranged from 19 to 74 years, and 9 of the 15 patients were male. The psychiatric diagnosis included major depression (5 patients), schizoaffective disorder (2 patients), dementia (2 patients), and bipolar disorder, dysthymia, conversion disorder, alcohol dependence, and personality disorder (1 patient each). Nine of the 15 patients were evaluated for competency to sign out of the hospital AMA, and the remaining 6 for refusing to undergo medical procedures. The authors did not provide other details (e.g., the criteria used in determining competency or the past and family psychiatric history of their patient population) or describe the outcome of the competency evaluation (including the likelihood that the consultee and the consultant would agree or disagree).
Our study, in contrast, involved a larger series of patients seen by three psychiatric consultation services. The use of such a methodology may increase the generalizability of our findings. We also used predetermined criteria set forth by Roth et al.1 to classify the competency evaluations into four categories. Not surprisingly, consultees were unlikely to ask for a consultation on patients in whom the risk-benefit ratio was unfavorable, irrespective of whether the patients agreed with the consultee or disagreed.
The remarkable similarities in the consultation requests across the three sites—as well as the lack of differences on demographic variables and on the rates of concordance and discordance of the competency evaluation between the consultee and consultant—speak to the generalizability of our findings to other general hospital settings. There were, however, a few minor demographic differences between the sites, which most likely reflects differences in the referral population. The consulting physician and the consultee agreed on the assessment of competency in 70% of the cases, which is similar to prior studies.12
Of the retrospective chart reviews3–10 of competency evaluation in general hospital settings, only a few have included a control group. These studies have found that patients with OMD are overrepresented, with rates of 52%–86% among the population that is found to be incompetent. Previous studies have also found that the patients evaluated for competency are somewhat older than the patients psychiatrically evaluated for other reasons. However, in those studies, the control groups have typically not been diagnosis-matched. In studies with a diagnostically matched control group, the age difference was not statistically significant. Retrospective chart reviews have also found that the psychiatric consultants were less likely to prescribe psychotropics to the patients evaluated for competency, compared with the patients evaluated for other reasons. This result may reflect differences in the nature of consultation requests. The treating physicians may have been more likely to request a psychiatric consultation to treat behavioral disturbances in one group of patients, whereas in another group, who were evaluated for competency, behavioral disturbances were not the predominant complaint.
The inherent limitations of our prospective study include a lack of a structured diagnostic interview and control group, inclusion of a relatively small number of patients (even though this is the largest prospective study yet cited in the literature), and the nature of the study population itself (medically ill patients being treated at tertiary-care hospitals), which may limit the generalizability of our findings.
Future studies should help target the population in which there is discordance between the consultee and the consultant in competency evaluations and establish guidelines that may help minimize this discrepancy.
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REFERENCES
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Roth LH, Meisel A, Lidz CW: Test of competency to consent to treatment. Am J Psychiatry 1977; 134:279–284[Abstract/Free Full Text]
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Gutheil TG, Appelbaum PS: Clinical Handbook of Psychiatry and the Law, 2nd Edition. Baltimore, MD, Williams & Wilkins, 1991
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Weinstock R, Copelan R, Bagheri A: Competence to give informed consent for medical procedures. Bull Am Acad Psychiatry Law 1984; 12:117–125[Medline]
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Strain JJ, Zebulon T, Gise LH, et al: Informed consent—mandating the consultation. Gen Hosp Psychiatry 1985; 7:228–233[Medline]
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Myers B, Barrett CL: Competency issues in referrals to a consultation-liaison service. Psychosomatics 1986; 27:782–788[Abstract/Free Full Text]
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Mebane AH, Rauch HB: When do physicians request competency evaluations? Psychosomatics 1990; 31:40–46[Abstract/Free Full Text]
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Mahler JC, Perry S, Miller F: Psychiatric evaluation of competency in physically ill patients who refuse treatment. Hospital and Community Psychiatry 1990; 41:1140–1141[Free Full Text]
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Golinger RC, Federoff JP: Characteristics of patients referred to psychiatrists for competency evaluations. Psychosomatics 1989; 30:296–299[Abstract/Free Full Text]
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Farnsworth MG: Competency evaluations in a general hospital. Psychosomatics 1990; 31:60–66[Abstract/Free Full Text]
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Jourdon JB, Glickman L: Reasons for requests of evaluation of competency in a municipal general hospital. Psychosomatics 1991; 32:413–416[Abstract/Free Full Text]
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McKegney FP, Schwartz BJ, O'Dowd MA: Reducing unnecessary psychiatric consultations for informed consent by liaison with administration. Gen Hosp Psychiatry 1992; 14:15–19[Medline]
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Cohen LM, McCue JD, Green GM: Do clinical and formal assessments of the capacity of patients in the intensive care unit to make decisions agree? Arch Intern Med 1993; 153:2481–2485[Abstract/Free Full Text]
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ABSTRACT
INTRODUCTION
