Reasons for Requests for Evaluation of Competency in a Municipal General Hospital B. JOURDAN, M.D. LEWIS GLICKMAN, M.D.
JOSETIE
During the periodfrom 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 ofmental illness. Seventy-five percent ofthe patients were found to be competent. Fear ofmedical legal consequences, physician's anxiety, lack of understanding ofthe rights ofpatients to refuse treatment, and a misunderstanding ofthe physician's duty when presented with such refusal seem to be the reasons for the large number of referrals.
I
n practice, psychiatrists often are asked to detennine the competency of hospitalized patients to sign out of the hospital against medical advice, to refuse a diagnostic or therapeutic procedure, or to refuse placement. H Frequently, there is no time available to bring a judge to the patient's bedside to decide on the patient's competency2..1; even when time is available, judges rarely come to the patient's bedside. At the same time, patients are often too sick to go to coun.2..1 In the general hospital setting, detennining the patient's competency is the responsibility ofconsultation-liaison (C-L) psychiatrists. At Kings County Hospital Center requests to our Col service for competency evaluation are many, constituting an imponant pan of the consultant's daily case load. The large number of these requests prompted us to conduct a study assessing their frequency and the reasons for them.
are age 16 and older. providing a total of 1.500 consultations a year: 1,300 at the municipal hospital and 200 at the university hospital. Patients under 16 years of age are seen by the child psychiatry service. We retrospectively reviewed the consultation repons for the months of July. August. and September 1989 and examined the referrals for evaluation of competency. Competency issues that came up during follow-up of cases were not included. RESULTS Out of 380 consultation repons reviewed, we found 95 referrals (25%) for evaluation of competency. The patients ranged in age from 18 to 83 years of age; 59 (62.10%) were men. and 36 (37.89%) were women. This compares with 56% men and 44% women for all of the referrals.
METHODS This study was conducted in a 1.200-bed municipal general hospital and a 368-bed university hospital operated by the state, both serving a largely minority. economically deprived population. Our Col service serves only patients who VOLUME 32· NUMBER 4' FALL 1991
Received July 12. 1990; revised November 5, 1990; accepted November 20. 1990. From the Lutheran Medical Center. Brooklyn; and the Kings County Hospital Center, Brooklyn. Address reprint requests to Dr. Jourdan, 34 Silver Street. Elmont. NY 11003 Copyright © 1991 The Academy of Psychosomatic Medicine.
413
Requests for Competency Evaluations
which is not significant by chi-square test at the 0.05 significance level. The criteria used to decide issues of competency are those described by Glickman. 4 Competency is assumed in the absence of evidence of mental illness. For a detennination of incompetency to be made, mental illness must be proven and must be ofsuch a degree that it interferes with the patient's ability to decide or to function in the specific situation at hand. Psychiatric diagnoses were made using DSM-III-R s criteria, some patients having more than one Axis-I diagnosis. Thirty patients received no psychiatric diagnosis, and an almost equal number (31) received a diagnosis of organic mental disorder. Nineteen patients admitted having a history of substance abuse; to were identified as having a psychotic disorder, 7 an adjustment disorder, 3 an affective disorder, and 3 a personality disorder. Assessment of competency for refusing a diagnostic or therapeutic procedure was the most common reason for referral, with a total of 53 cases (55.78%). Patients who asked to leave the hospital against medical advice constituted our second largest category, with a total of 26 cases (27.36%). The competency of a patient who consented to a procedure was questioned in II cases (11.57%). The remaining five referrals for assessment of competency were as follows: two for refusing placement (2.10%), one for refusing food (1.05%), and two for accepting or refusing treatment (2.10%). The procedures most often refused by patients included blood tests (n=IO), lumbar puncture (n=9), surgical procedures (biopsy, thoracocentesis, creation of a pericardial window, or abscess drainage) (n=7), and endoscopy (n=3). Seven patients refused a radiological procedure (CT scan, plain x-ray, gastrointestinal series, or myelogram). All fonns of treatment and nursing care were refused by 13 patients; 2 patients refused insertion of a nasogastric tube; 2 patients refused hemodialysis for end stage renal disease; and I patient refused to take any food. Of the 95 patients, 71 (74.73%) were found competent, and 24 (25.26%) were deemed incompetent. The group of competent patients included those 30 patients with no psychiatric 414
diagnosis. The incompetent patients either had an organic mental disorder (n=16) or an acute psychosis (n=8). Of the 71 competent patients, 5 changed their mind and consented to the proposed procedure or treatment either after talking to the psychiatrist (n=2) or before the psychiatric interview (n=3). Of these, one patient said he would accept the procedure after discussing it with his family. Two patients refused to be seen by the psychiatrist and were assumed competent based on infonnation gathered from the staff and chart review. One psychiatric assessment was judged irrelevant by the consultant because both the patient and her next of kin refused a diagnostic procedure. The remaining 63 patients were found competent to accept or to refuse procedure or treatment or to leave the hospital. Eighty-two (86.31 %) of the patients referred for competency detennination had refused treatment of some sort. Of these, 17 (20.73%) were found incompetent. Eleven patients who consented to a procedure had their competency questioned; five were declared incompetent to give an infonned consent. Two patients in our study were so grossly disorganized that the consultees questioned their ability to make any decisions at all, whether for or against treatment. The psychiatric consultant found both of these patients impaired in their capacity to make decisions. 6 As already noted, 53 ofthe 82 patients whose competency was assessed because of a refusal objected to a procedure: 35 refused a diagnostic test, and 18 refused therapy. Of these, 10 were found incompetent: 4 (11.42%) for refusing a diagnostic procedure and 6 (33.33%) for refusing a therapeutic procedure. Of the 26 patients who refused to stay in the hospital, 5 (18.46%) were found incompetent to sign out against medical advice. One of the two patients evaluated for her capacity to make a decision about her placement was found incompetent, as was a patient who refused to take any food. DISCUSSION The 1983-1986 study by Farnsworth l (presented as containing "the largest number of patients in a general hospital to be systematically reviewed PSYCHOSOMATICS
Jourdan and Glickman
regarding competency issues") found a 4% rate of referrals for competency evaluation. The study by Golinger and Fedoroff, 7 extending from 1981 to 1986, found a referral rate of 3.3%. In a study published in 1986, Myers and BarrettS reported a 15% rate. This study included competency issues that developed during follow-up of the cases, unlike our own present study, which was confined to initial consultation requests. In our institution an unpublished study in 1983 found a referral rate for competency evaluation of 16%, which included only competency to refuse. In 1989, the referral rate for assessment of competency in general was as high as 25%. We, however. did not find as high a rate of incompetent patients as Mebane and Rauch.9 who found that the proportion of competent and incompetent patients was roughly equal: 46% and 54%. respectively. as compared with our rate of 75% and 25%. respectively. Referrals for competency determination have now become almost routine and have extended beyond life-.limb-, or sight-saving issues to almost any instance in which a patient refuses a physician's advice. Poor doctor-patient relationship creates the selling for such referral for mental competency determinations. 9- '1 The physician. frustrated by rejection of what he or she considers to be in the patient's best medical interest. may refer the noncompliant patient for psychiatric evaluation:1. 12 The refusal may also be the patient's way of manifesting dissatisfaction with his or her care. Refusal. rather than acceptance, of a procedure is much more likely to trigger a request for psychiatric evaluation of competency.n.14 When we asked the requesting physicians (usually house officers) what made them question the competency of a patient referred for evaluation. they usually told us that they perceived the patient to be competent but that they wanted "documentation" by the psychiatrist so that they might "cover" themselves. Further inquiry reveals that the psychiatric referral often is initiated by a senior resident or by the allending physician. who is concerned that he or she might be cited by the local peer-review organization. The basis of this fear is that there is routine VOLUME 32· NUMBER 4· FALL 1991
inquiry by the peer-review organization as to why a recommended procedure was not performed if the patient's refusal is not documented, as it sometimes is not. By documenting the refusal. the psychiatric assessment on the chart seems to give the consultee a sense of medical legal security. It serves to reassure him or her that the consultant will bear the responsibility for any adverse consequences resulting from the patient's refusal; i.e.• they are "covered." Thus, the psychiatric consultation might serve a psychotherapeutic purpose for the anxious physician faced with a situation that may have a bad ending. In the affiliated university hospital setting. where many of the patients choose a physician who in tum agrees to treat them, competency referrals are less frequent. For the 3-month period covered by our study. only 5 out of 34 (14.7%) requests from the university hospital were for a determination of competency. In a local community hospital. one ofour consultants reported only 2 requests for competency evaluation out of 100 consecutive psychiatric referrals. Reasons for such apparent discrepancies between psychiatric referrals in municipal. university. and private hospitals may be due both to the decreased number of refusals in the laller two sellings and to the greater tolerance for refusal of treatment by private allending physicians than by house officers and salaried allending physicians. CONCLUSION Twenty-five percent of the referrals to our psychiatry C-L service in a 3-month period were for determination of competency. The physicians' fear of litigation and citation by the local peer-review organization is the main reason behind these frequent requests. These referrals seem less frequent in university hospitals and least frequent in a community hospital. The frequent referrals to psychiatrists for competency determination reflect a lack of understanding of a patient's right to refuse treatment. as well as a misunderstanding of the physician's duties in the presence of such refusal and in the absence of mental illness. II The President's Commission for the Study of Ethical 415
Requests for Competency Evaluations
Problems in Medicine and Biomedical and Behavioral Research6 stipulated that Decision making incapacity is not a medical or a psychiatric diagnostic category; it rests on a judgment of the type that an informed lay person might make that a patient lacks the ability to understand a situation and to make a choice in light of that understanding [po \721.
Failure of the physician to obtain the patient's consent is ev idence neither of the patient's
mental illness nor of the physician's vulnerability to litigation. especially if the physician has documented what he or she has told the patient. along with the patient's reply. Medical training should emphasize that many. if not most. patients are noncompliant with one or more recommendations of their physicians and that the responsibility of physicians is simply to infonn patients of the consequences (risks and benefits) of compliance and to accept refusal as the patients' privilege.
References I. Famswonh MG: Competency evaluations in a general hospital. Psychosomatics 31 :60--66. 1990 2. Appelbaum PS. Roth LH: Clinical issues in the assessment of competency. Am) Psychiatry 138:1462-1467. 1981 3. Weinstock R. Copelan R. Bagheri A: Physicians' confusion demonstrated by competency requests.) Forensic Sci 30:37-43. 1985 4. Glickman LS: Psychiatric Consultation in the General Hospital. in Experimental and Clinical Psychiatry. vol 3. Edited by Van Praag HM. Lader MH. Gershen S. et al. New York. Marcel Dekker. \980.234-251 5. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. 3rd Edition. Revised. Washington. DC. American Psychiatric Association. 1987 6. President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research: Making Health Care Decisions. Volume I: Report: The Ethical and Legal Implications ofInformed Consent in the Patient-Practitioner Relationship. Washington. DC. U.S. Government Printing Office. 1982. pp 55-{)8
416
7. Golinger RC. Fedoroff JP: Characteristics of patients referred to psychiatrists for competency evaluations. Psychosomatics 30:296-299. 1989 8. Myers B. Barrell CL: Competency issues in referrals to a consultation-liaison service. Psychosomatics 27:782789. 1986 9. Mebane AH. Rauch HB: When do physicians request competency evaluations? Psychosomatics 31 :4~6. \990
10. Lippen GP. Stewan DE: The psychiatrist's role in determining competency to consent in the general hospital. Can) Psychiatry 33:250-253. 1988 II. Appelbaum PS. Roth LH: Patients who refuse treatment in medical hospitals. )AMA 250:1296-1301. 1983 12. Aulbers BJM: Factors influencing referrals by general practitioners to consultants. in Decision Making in General Practice. Edited by Sheldon M. Brooke J. Rector A. New York. Macmillan. 1985. pp 131-140 13. Drane JF: The many faces of competency. The Hastings Cent Rep 15:17-21.1985 14. Brock OW. Wartman SA: When competent patients make irrational choices. N Enlll) Med 322: 1595-1599. 1990
PSYCHOSOMATICS
JOSETIE
During the periodfrom 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 ofmental illness. Seventy-five percent ofthe patients were found to be competent. Fear ofmedical legal consequences, physician's anxiety, lack of understanding ofthe rights ofpatients to refuse treatment, and a misunderstanding ofthe physician's duty when presented with such refusal seem to be the reasons for the large number of referrals.
I
n practice, psychiatrists often are asked to detennine the competency of hospitalized patients to sign out of the hospital against medical advice, to refuse a diagnostic or therapeutic procedure, or to refuse placement. H Frequently, there is no time available to bring a judge to the patient's bedside to decide on the patient's competency2..1; even when time is available, judges rarely come to the patient's bedside. At the same time, patients are often too sick to go to coun.2..1 In the general hospital setting, detennining the patient's competency is the responsibility ofconsultation-liaison (C-L) psychiatrists. At Kings County Hospital Center requests to our Col service for competency evaluation are many, constituting an imponant pan of the consultant's daily case load. The large number of these requests prompted us to conduct a study assessing their frequency and the reasons for them.
are age 16 and older. providing a total of 1.500 consultations a year: 1,300 at the municipal hospital and 200 at the university hospital. Patients under 16 years of age are seen by the child psychiatry service. We retrospectively reviewed the consultation repons for the months of July. August. and September 1989 and examined the referrals for evaluation of competency. Competency issues that came up during follow-up of cases were not included. RESULTS Out of 380 consultation repons reviewed, we found 95 referrals (25%) for evaluation of competency. The patients ranged in age from 18 to 83 years of age; 59 (62.10%) were men. and 36 (37.89%) were women. This compares with 56% men and 44% women for all of the referrals.
METHODS This study was conducted in a 1.200-bed municipal general hospital and a 368-bed university hospital operated by the state, both serving a largely minority. economically deprived population. Our Col service serves only patients who VOLUME 32· NUMBER 4' FALL 1991
Received July 12. 1990; revised November 5, 1990; accepted November 20. 1990. From the Lutheran Medical Center. Brooklyn; and the Kings County Hospital Center, Brooklyn. Address reprint requests to Dr. Jourdan, 34 Silver Street. Elmont. NY 11003 Copyright © 1991 The Academy of Psychosomatic Medicine.
413
Requests for Competency Evaluations
which is not significant by chi-square test at the 0.05 significance level. The criteria used to decide issues of competency are those described by Glickman. 4 Competency is assumed in the absence of evidence of mental illness. For a detennination of incompetency to be made, mental illness must be proven and must be ofsuch a degree that it interferes with the patient's ability to decide or to function in the specific situation at hand. Psychiatric diagnoses were made using DSM-III-R s criteria, some patients having more than one Axis-I diagnosis. Thirty patients received no psychiatric diagnosis, and an almost equal number (31) received a diagnosis of organic mental disorder. Nineteen patients admitted having a history of substance abuse; to were identified as having a psychotic disorder, 7 an adjustment disorder, 3 an affective disorder, and 3 a personality disorder. Assessment of competency for refusing a diagnostic or therapeutic procedure was the most common reason for referral, with a total of 53 cases (55.78%). Patients who asked to leave the hospital against medical advice constituted our second largest category, with a total of 26 cases (27.36%). The competency of a patient who consented to a procedure was questioned in II cases (11.57%). The remaining five referrals for assessment of competency were as follows: two for refusing placement (2.10%), one for refusing food (1.05%), and two for accepting or refusing treatment (2.10%). The procedures most often refused by patients included blood tests (n=IO), lumbar puncture (n=9), surgical procedures (biopsy, thoracocentesis, creation of a pericardial window, or abscess drainage) (n=7), and endoscopy (n=3). Seven patients refused a radiological procedure (CT scan, plain x-ray, gastrointestinal series, or myelogram). All fonns of treatment and nursing care were refused by 13 patients; 2 patients refused insertion of a nasogastric tube; 2 patients refused hemodialysis for end stage renal disease; and I patient refused to take any food. Of the 95 patients, 71 (74.73%) were found competent, and 24 (25.26%) were deemed incompetent. The group of competent patients included those 30 patients with no psychiatric 414
diagnosis. The incompetent patients either had an organic mental disorder (n=16) or an acute psychosis (n=8). Of the 71 competent patients, 5 changed their mind and consented to the proposed procedure or treatment either after talking to the psychiatrist (n=2) or before the psychiatric interview (n=3). Of these, one patient said he would accept the procedure after discussing it with his family. Two patients refused to be seen by the psychiatrist and were assumed competent based on infonnation gathered from the staff and chart review. One psychiatric assessment was judged irrelevant by the consultant because both the patient and her next of kin refused a diagnostic procedure. The remaining 63 patients were found competent to accept or to refuse procedure or treatment or to leave the hospital. Eighty-two (86.31 %) of the patients referred for competency detennination had refused treatment of some sort. Of these, 17 (20.73%) were found incompetent. Eleven patients who consented to a procedure had their competency questioned; five were declared incompetent to give an infonned consent. Two patients in our study were so grossly disorganized that the consultees questioned their ability to make any decisions at all, whether for or against treatment. The psychiatric consultant found both of these patients impaired in their capacity to make decisions. 6 As already noted, 53 ofthe 82 patients whose competency was assessed because of a refusal objected to a procedure: 35 refused a diagnostic test, and 18 refused therapy. Of these, 10 were found incompetent: 4 (11.42%) for refusing a diagnostic procedure and 6 (33.33%) for refusing a therapeutic procedure. Of the 26 patients who refused to stay in the hospital, 5 (18.46%) were found incompetent to sign out against medical advice. One of the two patients evaluated for her capacity to make a decision about her placement was found incompetent, as was a patient who refused to take any food. DISCUSSION The 1983-1986 study by Farnsworth l (presented as containing "the largest number of patients in a general hospital to be systematically reviewed PSYCHOSOMATICS
Jourdan and Glickman
regarding competency issues") found a 4% rate of referrals for competency evaluation. The study by Golinger and Fedoroff, 7 extending from 1981 to 1986, found a referral rate of 3.3%. In a study published in 1986, Myers and BarrettS reported a 15% rate. This study included competency issues that developed during follow-up of the cases, unlike our own present study, which was confined to initial consultation requests. In our institution an unpublished study in 1983 found a referral rate for competency evaluation of 16%, which included only competency to refuse. In 1989, the referral rate for assessment of competency in general was as high as 25%. We, however. did not find as high a rate of incompetent patients as Mebane and Rauch.9 who found that the proportion of competent and incompetent patients was roughly equal: 46% and 54%. respectively. as compared with our rate of 75% and 25%. respectively. Referrals for competency determination have now become almost routine and have extended beyond life-.limb-, or sight-saving issues to almost any instance in which a patient refuses a physician's advice. Poor doctor-patient relationship creates the selling for such referral for mental competency determinations. 9- '1 The physician. frustrated by rejection of what he or she considers to be in the patient's best medical interest. may refer the noncompliant patient for psychiatric evaluation:1. 12 The refusal may also be the patient's way of manifesting dissatisfaction with his or her care. Refusal. rather than acceptance, of a procedure is much more likely to trigger a request for psychiatric evaluation of competency.n.14 When we asked the requesting physicians (usually house officers) what made them question the competency of a patient referred for evaluation. they usually told us that they perceived the patient to be competent but that they wanted "documentation" by the psychiatrist so that they might "cover" themselves. Further inquiry reveals that the psychiatric referral often is initiated by a senior resident or by the allending physician. who is concerned that he or she might be cited by the local peer-review organization. The basis of this fear is that there is routine VOLUME 32· NUMBER 4· FALL 1991
inquiry by the peer-review organization as to why a recommended procedure was not performed if the patient's refusal is not documented, as it sometimes is not. By documenting the refusal. the psychiatric assessment on the chart seems to give the consultee a sense of medical legal security. It serves to reassure him or her that the consultant will bear the responsibility for any adverse consequences resulting from the patient's refusal; i.e.• they are "covered." Thus, the psychiatric consultation might serve a psychotherapeutic purpose for the anxious physician faced with a situation that may have a bad ending. In the affiliated university hospital setting. where many of the patients choose a physician who in tum agrees to treat them, competency referrals are less frequent. For the 3-month period covered by our study. only 5 out of 34 (14.7%) requests from the university hospital were for a determination of competency. In a local community hospital. one ofour consultants reported only 2 requests for competency evaluation out of 100 consecutive psychiatric referrals. Reasons for such apparent discrepancies between psychiatric referrals in municipal. university. and private hospitals may be due both to the decreased number of refusals in the laller two sellings and to the greater tolerance for refusal of treatment by private allending physicians than by house officers and salaried allending physicians. CONCLUSION Twenty-five percent of the referrals to our psychiatry C-L service in a 3-month period were for determination of competency. The physicians' fear of litigation and citation by the local peer-review organization is the main reason behind these frequent requests. These referrals seem less frequent in university hospitals and least frequent in a community hospital. The frequent referrals to psychiatrists for competency determination reflect a lack of understanding of a patient's right to refuse treatment. as well as a misunderstanding of the physician's duties in the presence of such refusal and in the absence of mental illness. II The President's Commission for the Study of Ethical 415
Requests for Competency Evaluations
Problems in Medicine and Biomedical and Behavioral Research6 stipulated that Decision making incapacity is not a medical or a psychiatric diagnostic category; it rests on a judgment of the type that an informed lay person might make that a patient lacks the ability to understand a situation and to make a choice in light of that understanding [po \721.
Failure of the physician to obtain the patient's consent is ev idence neither of the patient's
mental illness nor of the physician's vulnerability to litigation. especially if the physician has documented what he or she has told the patient. along with the patient's reply. Medical training should emphasize that many. if not most. patients are noncompliant with one or more recommendations of their physicians and that the responsibility of physicians is simply to infonn patients of the consequences (risks and benefits) of compliance and to accept refusal as the patients' privilege.
References I. Famswonh MG: Competency evaluations in a general hospital. Psychosomatics 31 :60--66. 1990 2. Appelbaum PS. Roth LH: Clinical issues in the assessment of competency. Am) Psychiatry 138:1462-1467. 1981 3. Weinstock R. Copelan R. Bagheri A: Physicians' confusion demonstrated by competency requests.) Forensic Sci 30:37-43. 1985 4. Glickman LS: Psychiatric Consultation in the General Hospital. in Experimental and Clinical Psychiatry. vol 3. Edited by Van Praag HM. Lader MH. Gershen S. et al. New York. Marcel Dekker. \980.234-251 5. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. 3rd Edition. Revised. Washington. DC. American Psychiatric Association. 1987 6. President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research: Making Health Care Decisions. Volume I: Report: The Ethical and Legal Implications ofInformed Consent in the Patient-Practitioner Relationship. Washington. DC. U.S. Government Printing Office. 1982. pp 55-{)8
416
7. Golinger RC. Fedoroff JP: Characteristics of patients referred to psychiatrists for competency evaluations. Psychosomatics 30:296-299. 1989 8. Myers B. Barrell CL: Competency issues in referrals to a consultation-liaison service. Psychosomatics 27:782789. 1986 9. Mebane AH. Rauch HB: When do physicians request competency evaluations? Psychosomatics 31 :4~6. \990
10. Lippen GP. Stewan DE: The psychiatrist's role in determining competency to consent in the general hospital. Can) Psychiatry 33:250-253. 1988 II. Appelbaum PS. Roth LH: Patients who refuse treatment in medical hospitals. )AMA 250:1296-1301. 1983 12. Aulbers BJM: Factors influencing referrals by general practitioners to consultants. in Decision Making in General Practice. Edited by Sheldon M. Brooke J. Rector A. New York. Macmillan. 1985. pp 131-140 13. Drane JF: The many faces of competency. The Hastings Cent Rep 15:17-21.1985 14. Brock OW. Wartman SA: When competent patients make irrational choices. N Enlll) Med 322: 1595-1599. 1990
PSYCHOSOMATICS
