Psychosomatics 40:28-33, February 1999
© 1999 The Academy of Psychosomatic Medine
Competency Evaluations on the Consultation-Liaison Service
Some Overt and Covert Aspects
C. Umapathy, M.D.,
Dilip Ramchandani, M.D.,
Ruth M. Lamdan, M.D.,
Lori A. Kishel, M.S.W., L.S.W., and
Barbara A. Schindler, M.D.
Received April 28, 1998; revised July 6, 1998; accepted August 28, 1998. From the Consultation-Liaison Psychiatry Division, the Department of Psychiatry, theAllegheny University Hospitals—MCP Division, Philadelphia, Pennsylvania. Address reprint requests to Dr. Ramchandani, Consultation-Liaison Psychiatry Division, Department of Psychiatry/Allegheny University Hospital–MCP Division, 3300 Henry Avenue, Philadelphia, PA 19129.
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ABSTRACT
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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.
Key Words: Competency • Consultation-Liaison • Patient Rights
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INTRODUCTION
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Competency assessments in the general hospital setting are an important and growing function of the consultation-liaison (C-L) psychiatrist. These requests may constitute as many as 10%–25% of all psychiatric consultations.1,2 A decrease in the inpatient length of stay and the increasing complexity of medical treatment may have contributed to the greater frequency of such consultations.3 Much attention, therefore, has been focused on this function in the recent literature in C-L psychiatry.4–14 Many authors have addressed themselves to the process and criteria of competency determination.4–9 Others have described the catalysts for competency evaluation in the general hospital, the characteristics of such patients, and the impact of the psychiatrist's opinion on the course of the patient's management.10–14
Treatment refusal, incapacity to give informed consent to complicated procedures, threats to leave the hospital against medical advice (AMA), and inability to care for self and to manage finances for independent living have generally been recognized as the stated reasons that prompt consultation requests for competency assessment.11–13 However, the literature on the process of competency evaluation and its impact on the outcome of hospitalization is ambiguous. As a result, C-L psychiatrists often find themselves in the unenviable position of having to 1) abstract usable criteria from a confusing array of models for competency assessment replete with legal jargon, 2) respond to the administrative pressure to keep patients moving in and out of the hospital rapidly, 3) interpret legal standards and conventions that vary from time to time and from place to place, 4) consider the sophisticated nature of multiple treatment options and their associated risks and benefits, and 5) intervene to salvage the doctor–patient alliance threatened by transference/countertransference issues.
The source of such ambiguity may lie in the covert aspects of the nature and the process of competency consultation. Katz et al. have referred to the "unspoken but clear expectation" on the part of the treatment team, perhaps naively so, that the patient will be found incompetent so that treatment can proceed.14 These authors have warned the C-L psychiatrists of the risk of colluding in a subtle coercion of the patient and point to the growing appreciation of the liaison function of the consulting psychiatrist in mediating an agreement between the patient and his or her doctors about treatment. Masand et al. have, on the other hand, identified two subgroups of patients based upon the degree of concordance in the competency assessment of the psychiatrist and the referring physician and the need for further study of patients about whose competency there is disagreement between the two.15
Our study is an attempt to clarify the covert aspects of a consultation for competency assessment in a medical–surgical setting by examining the impact of such psychiatric consultations on the subsequent course of the patient's stay in the hospital. In doing so, some of the specific challenges and pitfalls of the process of competency determination will be identified.
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METHODS
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The study was conducted in an urban, 300-bed, teaching general hospital. The patient population is drawn largely from an impoverished inner-city neighborhood, and the payor mix is predominantly Medicare and Medicaid health maintenance organizations, with some private insurers, mostly for cardiac patients. The psychiatric C-L service sees about 800 patients annually. In the study period between October 1996 and June 1997, 673 consultations were done, of which 50 consultations were for competency evaluation. In evaluating these patients, the psychiatrist generally followed the guidelines suggested by Applebaum and Grisso5 and Drane7 Applebaum and Grisso base the determination of competency on the patient's ability to 1) appreciate the situation and its consequences, 2) understand the relevant information and manipulate it rationally, and 3) communicate choice. Drane recommends using a sliding scale for establishing a threshold for competency depending on the relative risk and benefit of a procedure or treatment. Consultations were performed by a team of a psychiatric resident and an attending physician, and diagnoses were made by using DSM-IV criteria.
Forty-six out of the 50 charts could be retrieved and were retrospectively reviewed by two of the authors (CU, DR). The review included the medical notes, the psychiatric consultation, and follow-ups, including the Folstein Mini-Mental State Exam16 that we routinely administer to all our patients on the C-L service, as well as notes written by the social workers and case managers. Items listed in Table 1 were analyzed.
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RESULTS
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Thirty of 46 patients who were referred for competency assessment were age 60 or older (64%), and 27 of 46 were men (58%). During the study period, 45% of all the patients seen by the C-L service were over age 60, and 53% were women. These data were subjected to chi-square analysis, and a P-value was calculated by a two-tailed t-test. The age difference was significant (P=0.005), but the gender difference was not (P=0.099). Consultations in the study group were more likely to be requested in the first third of the hospital stay (50%). Consultation requests received in the last third of hospitalization (26%) were usually prompted by disposition concerns.
The reasons for competency assessment included outright refusal of the treatment recommendations or uncooperativeness with treatment, often resulting from patient confusion or ambivalence. In many cases, the referring physicians had difficulty communicating the need for a particular treatment and obtaining informed consent. The remaining patients were reluctant to accept the treatment teams' recommendations for placement postdischarge (Table 2).
In 7 of the 46 patients in our study, the medical treatment teams decided that their earlier diagnostic or treatment recommendations were no longer necessary, so the issue of competency assessment was rendered moot. The outcome of the consultation and the impact of competency determination on the course of the patients' hospital stay was determined in the remaining 39 patients. Of these, 22 were found to lack the capacity for competent decision making and 11 were deemed competent. In six patients, the competency determination was not made because the patient readily agreed to the recommendations (3/6), a compromise between the treatment team and the patient on an acceptable alternative was reached (2/6), or the patient was discharged before the C-L psychiatrist determined competency (1/6).
In following the course of 22 patients who were assessed as incompetent, it was found that in 14 patients, treatment proceeded per the recommendations of the treatment team. Seven of these patients improved with psychiatric intervention, usually for delirium, and became cooperative with treatment. The family or friends of seven patients allowed the treatment to proceed. In four out of the remaining eight patients, a compromise between the patient and the treatment team was worked out with help from the C-L team. Four patients were rather abruptly discharged.
Of the 11 patients who were found to be competent, 7 accepted the proffered treatment after C-L intervention, 1 was eventually persuaded to accept, and 3 continued to refuse. All three patients who refused were discharged within 24–48 hours (Figure 1 and Figure 2).
Table 3 shows the results of the Folstein examination. Only 24/46 patients were able to cooperate with the administration of this brief scale, so the assessment of competency was based largely on a clinical history and mental status examination. Table 4 and Table 5 show the psychiatric diagnoses given to these patients and the treatment interventions and recommendations made by the C-L psychiatrists.
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DISCUSSION
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As anticipated, our study confirmed the findings of earlier studies on the reasons that prompt competency consultation requests. Often, the typical situation was that of a confused patient who did not appreciate either the need for or nature of the treatment being recommended, which led to either refusal, ambivalent acceptance, or indecisiveness, much to the frustration of the treatment team. Most of these patients, not surprisingly, were diagnosed to have some form of a cognitive disorder, such as dementia or delirium (65%), as has been previously reported.1,12–14,17
It was also not surprising that eventually a large percentage of the patients in our study (43%), as in some prior studies, fully accepted the recommendations of their physicians.14,18 Fifteen percent of our patients agreed to a compromise facilitated by the psychiatrist among the patient, the patient's family, and the treating physician. In another 20% of the patients who remained unwilling to accept treatment, our decision about their lack of competency led to the assumption of medical decision making by their families or friends, who, in turn, agreed with the physician's recommendations.
Thus, the facilitatory role of the C-L psychiatrist seemed to be confirmed by our study, but a closer look at the nature of our facilitation revealed some interesting findings (Table 5). Psychotropic medication was prescribed in 14/46 patients, which may have helped improve their mental status and led to a clearer understanding of treatment recommendations. The most frequent psychiatric intervention, however, was limited to recommending and encouraging involvement of family and friends in the care of these patients. Indeed, a psychiatric consultation was often requested even before an attempt had been made to communicate with the patients' important support network.
Berlin and Canaan have asserted that involvement of the family in medical decision making turns potentially legal problems into those that can be solved by the patient, family, and other members of the patient's support network.19 Yet in our study, most families were uninvolved until we brought them in. There might be several reasons for the inadequate communication between the treating physicians and the families of these patients. The inadequacy might stem from a reluctance in families of poor inner-city patients to get involved because members might be intimidated by the hospital setting. Alternatively, the families might be unable or unwilling to be emotionally or materially involved with the care of their sick relatives. Family nonparticipation might also reflect the inability of the physician to find the time to reach out to the families, especially as the pressure to reduce the length of stay continues to increase in the current managed care environment.
Another interesting issue involved the eight "incompetent" patients who continued to refuse the proposed treatments (20% of the study group). They were all suddenly or unexpectedly discharged from the hospital. The following two brief vignettes illustrate our experience with these patients.
Case 1. Ms. J., a 53-year-old woman with a long history of alcoholism and hypertension, was admitted with the diagnosis of acute subarachnoid hemorrhage. A craniotomy was performed, and a right-sided, internal, carotid-artery aneurysm was clipped. The patient remained confused and disinhibited, although alert for several days postoperatively. Neuropsychological testing confirmed significant residual cognitive impairment. The patient had lived alone after a recent separation from husband, had no social support, and had been placed on disability from her position as school teacher 2 years earlier. She refused placement services. Psychiatric assessment revealed lack of capacity to make informed decision about disposition and ability to live independently. The patient was discharged by the treatment team unexpectedly on the weekend, even as the rest of us (the treatment team) pondered on how best to address these concerns.
Case 2. Mr. L., a 42-year-old man with a history of substance abuse and AIDS (acquired immunodeficiency syndrome), was admitted overnight with chest pain to rule out pulmonary embolus. In the morning, he became argumentative and threatened to sign out AMA. The patient was too agitated to cooperate with a thorough psychiatric evaluation. However, it was clear that he lacked the capacity to make an informed decision about the risks involved in his intention to leave the hospital at the time. Even as we attempted to involve people in the patient's life who might help calm his agitation, the patient was allowed to leave AMA.
In these situations, it appeared as if the consultee essentially wanted the C-L psychiatrist to support his or her decision to discharge the patient. Katz et al. have reported that the consulting psychiatrist is often under pressure to declare the patient incompetent to support the medical team's wish to intervene.14 Interestingly, we identified a subgroup of patients in whom the pressure, paradoxically, was to declare the patient competent so that he/she could be quickly discharged. Schlauch et al., in their study of patients who signed out AMA, had found that a subtle agreement may have existed between some patients and the staff that termination of hospitalization was acceptable despite the element of medical risk involved.20 Our assessment of incompetency, when conveyed to the treatment team, may have accentuated the frustration in managing these patients whose psychosocial needs were greater than usual. The impatience of the treatment teams was also evident in their reluctance to involve hospital ethics committees and legal services departments when such consultations were suggested by the psychiatrists. A possible explanation may lie in the increased reorganization of traditional hospital roles, so that the responsibilities of the hospital-based social workers, who have hitherto served as a bridge between the patients and their communities, have been redefined and pared down.21–23 As traditional social services are further scaled back or even eliminated, the expectation to solve all psychosocial problems, including the task of communicating with the families, may have shifted to the C-L services in some hospitals.
Thus, our findings suggest that the request for competency assessment is often a euphemism for physicians' frustration in managing some patients who are unable to progress smoothly along the course of their hospitalization. Inadequate attention to the psychosocial context of these patient's medical needs may well be an important source of such difficulties. This problem may be aggravated by the ever-increasing financial constraints and resulting reductions in the workforce, especially social services. Unfortunately, C-L psychiatrists may not be able to provide the appropriate remedies—or fill the gap—in all such cases.
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Schindler BA, Lamdan RM, Ramchandani D, et al: Changing face of C-L psychiatry in an urban setting (abstract). Atlanta, GA, Proceedings of the Academy of Psychosomatic Medicine Annual Meeting, 1991
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ABSTRACT
INTRODUCTION
