Psychiatric ‘holds’ for nonpsychiatric patients

Variety 2: lucid patients who refuse treatment. Patients who do not have obvious psychiatric problems may refuse necessary medical or surgical treatment for various reasons: obstinacy, distrust of doctors, fear, ignorance, incorrect but firmly held ideas about body functioning, cultural differences, or religious beliefs. None of these reasons is necessarily psychopathological, and none provides justification for a psychiatric hold.

Key determinant: Competence

Refusing treatment may be a bad choice and sometimes is evidence of a mental disorder, but it is not, by itself, a mental disorder. When a Variety 2 adult patient refuses care, the key question is, “Is this a competent refusal?” Assessment of a patient’s capacity to make medical decisions is not a skill unique to psychiatrists. Other specialists make judgments about capacity routinely—if only implicitly—when they elicit their patients’ informed consent for care. But when, as in Mr. J’s case, a seriously ill medical-surgical patient refuses lifesaving treatment, our medical colleagues often get psychiatrists involved. Consulting a psychiatrist in such circumstances makes sense, for at least 4 reasons:

• Although assessment of decision-making isn’t the special province of psychiatry, psychiatrists often have more experience assessing the capacity of persons whose thinking seems impaired.
• Psychiatrists also have more experience in detecting subtle indications of mental disorders (eg, mild dementia, depression, psychosis) that can compromise decision-making capacity.
• A nonpsychiatrist may believe that a patient is making a competent refusal but still wants a psychiatrist’s perspective to better understand the patient’s reasoning or to confirm the initial belief.
• Getting an independent opinion is a prudent way to make sure one’s emotions are not adversely influencing a critical judgment about a patient’s treatment.

Determining whether a patient has the requisite capacity to refuse care involves a situation-specific assessment of 4 aspects of mental functioning: expressing a choice coherently, understanding relevant information, appreciating this information, and using the information rationally. Table 2⁹ describes these functional areas in more detail.

Table 2

Evaluating the quality of a patient’s decision: 4 dimensions

If capacity is lacking, what next?

As Judge Benjamin Cardozo ruled nearly a century ago, “Every human being of adult years and sound mind has a right to determine what shall be done with his own body.”¹⁰ In a case such as Mr. J’s, where a patient wants to leave the hospital or refuses medical treatment despite grave risk to himself, staff members should not let him leave until his treating doctors have tried to clarify his reasons for leaving and determined whether he has the capacity to give informed consent and refuse treatment. Psychiatrists may be consulted in this process, although the final judgment about capacity rests with the responsible physician. If an assessment shows that the patient has the capacity to make medical decisions, his treatment refusal is binding, even when it creates a clear risk of death.

What should happen if an assessment shows that a gravely ill patient lacks capacity to refuse treatment? Clinicians should consult with the hospital attorney about their facility’s policies and how to implement them properly.

Thinking about the possible legal implications of their actions, treating clinicians might worry that if they detain an unwilling patient without authorization from a court or guardian, they would risk being sued later for false imprisonment. But attorneys are likely to advise clinicians that they have more to fear liability-wise from letting incompetent patients leave the hospital than from detaining them for their own safety. As an Ohio court commented about a police officer who stopped a patient from leaving the hospital:

• What in the name of all that is reasonable should the officer have done? The court finds that the officer acted properly under the circumstances known to him at the time—and the reasonableness of an officer’s actions must be judged at the exigent split second on the street…¹¹