Dear Dr. Mossman,
At the general hospital where I perform consultations, the medical service asked me to fill out psychiatric “hold” documents to keep a severely malnourished young woman with anorexia nervosa from leaving the hospital. Ms. Q, whose body mass index (BMI) was 12 (yes, 12), came to the hospital to have her “electrolytes fixed.” She was willing to stay the night for electrolyte repletion, but insisted she could gain weight on her own at home.
I’m worried that she might die without prompt inpatient treatment; she needs to stay on the medical service. Should I fill out a psychiatric hold to keep her there? What legal risks could I face if Ms. Q is detained and force-fed against her will? What are the legal risks of letting her leave the hospital before she is medically stable?
Submitted by “Dr. F”
When a severely malnourished patient with an eating disorder arrives on a medical floor, treatment teams often ask psychiatric consultants to help them impose care the patient desperately needs but doesn’t want. This reaction is understandable. After all, an eating disorder is a psychiatric illness, and hospital-based psychiatrists have experience with treating involuntary patients. A psychiatric hold may seem like a sensible way to save the life of a hospitalized patient with a mental illness.
But filling out a psychiatric hold only scratches the surface of what a psychiatric consultant’s contribution should include; in Ms. Q’s case, initiating a psychiatric hold is probably the wrong thing to do.
Why would filling out a psychiatric hold be inappropriate for Ms. Q? What clinical factors and legal issues should a psychiatrist consider when helping medical colleagues provide unwanted treatment to a severely malnourished patient with an eating disorder? We’ll explore these matters as we consider the case of Ms. Q (Figure) and the following questions:
- What type of care is most appropriate for her now?
- Can she refuse medical treatment?
- What are the medicolegal risks of letting her leave the hospital?
- What are the medicolegal risks of detaining and force-feeding her against her will?
- When is a psychiatric “hold” appropriate?
What care is appropriate?
Given her state of self-starvation, Ms. Q’s treatment plan could require close monitoring of her electrolytes and cardiac status, as well as watching her for signs of “refeeding syndrome”—rapid, potentially fatal fluid shifts and metabolic derangements that malnourished patients could experience when they receive artificial refeeding.1
First, the physicians who are caring for Ms. Q should determine whether she needs more intensive medical supervision than is usually available on a psychiatric unit. If she does, but she won’t agree to stay on a medical unit for care, a psychiatric hold is the wrong step, for 2 reasons:
- Once a psychiatric hold has been executed, state statutes require the patient to be placed in a psychiatric facility—a state-approved psychiatric treatment setting, such as a psychiatric unit or free-standing psychiatric hospital—within a specified period.2,3 Most nonpsychiatric medical units would not meet state’s statutory definition for such a facility.
- A psychiatric hold only permits short-term detention. It does not provide legal authority to impose unwanted medical treatment.
Does Ms. Q have capacity?
In the United States, Ms. Q has a legal right to refuse medical care—even if she needs it urgently—provided that her refusal is made competently.4 As Appelbaum and Grisso5 explained in a now-classic 1988 article:
The legal standards for competence include the four related skills of communicating a choice, understanding relevant information, appreciating the current situation and its consequences, and manipulating information rationally.
The Table5 describes these abilities in more detail.
Only courts can make legal determinations of competence, so physicians refer to an evaluation of a patient’s competence-related abilities as a “capacity assessment.” The decision as to whether a patient has capacity ultimately rests with the primary treatment team; however, physicians in other specialties often enlist psychiatrists’ help with this matter because of their interviewing skills and knowledge of how mental illness can impair capacity.
No easy-to-use instrument for evaluating capacity is available. However, Appelbaum6 provides examples of questions that often prove useful in such assessments, and a review by Sessums et al7 on several capacity evaluation tools suggests that the Aid to Capacity Evaluation8 may be the best instrument for performing capacity assessments.
Patients with anorexia nervosa often differ substantially from healthy people in how they assign values to life and death,9 which can make it difficult to evaluate their capacity to refuse life-saving treatment. Malnutrition can alter patients’ ability to think clearly, a phenomenon that some patients with anorexia mention as a reason they are grateful (in retrospect) for the compulsory treatment they received.10 Yet, if an evaluation shows that the patient has the decision-making capacity to refuse care, then her (his) caregivers should carefully document this conclusion and the basis for it. Although caregivers might encourage her to accept the treatment they believe she needs, they should not provide treatment that conflicts with their patient’s wishes.