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Competency Evaluations in a General Hospital
Competency Evaluations in a General Hospital MICHAEL
G.
FARNSWORTH. M.D.
This study describes 90 requests for competency evaluation received by a psychiatry consultation service between 1983 and 1986. Most ofthe requests were prompted by a patient's refusal to accept a physician's recommendations regarding treatment or disposition. Delirium and dementia accountedfor the majority ofdiagnoses in the population deemed incompetent. Consultees were more likely to follow recommendations for further medical evaluation than to obtain recommended guardianships, living-skill assessments, or neuropsychometric testing. Guardianships were establishedfor only seven of26 patients deemed incompetent. This study demonstrates the needfor consulting psychiatrists to be aware ofthe forensic issues ofcompetency.
ompetency is a legal construct that has clinical relevance for medical practitioners. Broadly conceptualized, it is an individual's ability to adequately handle his or her personal affairs consonant with personal autonomy-the right to make deliberate decisions within the context of one's life goals and preferences. All adults are presumed competent unless a court adjudicates otherwise. The legal definitions of incompetence are vague and demonstrate considerable variation in terms and basic elements from state to state. Some states apply a single statutory definition of incompetence; others apply an array of definitions for different purposes. Gutheil and Appelbaum l point out that the net result of these various laws is to provide the court with maximum flexibility in determining competence. A recent Presidential commission2 on competency concluded that the core elements of competence included the possession of a set of values and
C
Received September 15. 1988; revised January 30. 1989; accepted February 21.1989. Address reprint requests to Dr. Famswonh. Depanment of Psychiatry. Ramsey Clinic. St. Paul-Ramsey Foundation. 640 Jackson Street. St. Paul. MN 55101. Copyright © 1990 The Academy of Psychosomatic Medicine.
60
goals, the ability to communicate and understand information, and the ability to reason and to deliberate. In the hospital setting, competency issues usually revolve around a patient's consent to, or refusal of, medical treatment and the capacity to safely care for oneself and one's property. Psychiatrists are often asked to render an opinion regarding an individual's competence. A psychiatric finding of incompetence remains only an opinion until it is confirmed by a judicial ruling on the evidence. However, the psychiatric evaluation is often the cornerstone of a judicial determination of incompetence. Attempts to clarify the clinical evaluation of competence have been made,J.-S but competency remains largely an issue determined by an impressionistic collection of bedside mental status examinations. Despite medical practitioners' reliance on psychiatric evaluation ofcompetency, few studies have characterized the population of patients examined for competence. Myers and Barrett6 examined 100 retrospective and 100 prospective consultations for issues related to medical patients' competency to make decisions about treatment. They found that the patients prompting requests for competency evaluations fell into three categories. One group had PSYCHOSOMATICS
Farnsworth
been admitted to the hospital comatose because they had inflicted self-hann; upon recovery, they refused treatment or demanded discharge. A second group comprised elderly patients with cognitive deficits. The third group comprised patients who posed management problems. The most frequent issue prompting requests for competency evaluation was a threat to leave the hospital against medical advice. Weinstock et a1. 7 conducted 30 assessments of competence to give informed consent at a Veterans Administration hospital. They discovered that only patients with organic brain syndromes were found incompetent. They also demonstrated that patients who refused medical treatment were more commonly referred forevaluation of competence than were patients who accepted treatment. Few schizophrenic patients were referred for evaluation, and none were found incompetent. This study describes the outcomes of competency examinations conducted by a psychiatry consultation service in a general hospital. Competency evaluation requests were reviewed, and data concerning the requesting service, specific competency question, Diagnostic and Statistical Manual of Mental Disorders. Third Edition (DSM-llll diagnoses, and recommendations were recorded. The patients' records were then examined to assess compliance with the recommendations and outcomes of the hospitalizations in which the competency question arose. METHODS St. Paul-Ramsey Medical Center is a 272-bed, university-affiliated, teaching hospital that treats both indigent and privately insured individuals. The psychiatry consultation-liaison service received an average of 50 referrals per month between 1983 and 1986; it was staffed by two board-certified psychiatrists. Fourth-yearpsychiatric residents completing an elective in consultation psychiatry, first year residents, and medical students rounded out the service team. All of the psychiatric consultations conducted between 1983 and 1986 were retrospectively reviewed. Referrals specifically for VOLUME31-NUMBER I-WINTER 1990
competency assessment were identified and subjected to a chart review of the hospitalization course that prompted the consultation request. Each consultation report contained a clinical history of the competency issue, social history, past medical history, mental status examination, diagnosis, and a brief discussion of the conclusions and recommendations. Demographic data (age, sex, and race), the service requesting consult, the specific competence question raised, DSM-lll Axis I and II diagnoses, consultant's recommendations, and compliance with recommendations from each consultation were recorded. The retrospective nature ofthis study did not permit a more detailed analysis of the criteria used by the consulting psychiatrist to determine competency. Statistical analysis of the data included cross-tabulation, chi-square, t-test, and analysis of variance using the Statistical Package for the Social Sciences.9 RESULTS The consultation service completed 2,340 assessments between January 1983 and December 1986. Ninety (3.8%) requests were for competency evaluation. The internal medicine department made 57 (63%) requests; orthopedics, neurology, and obstetrics/gynecology requested 25 (28%) evaluations. Surgery requested only four (4.4%) competency evaluations, and four services (radiology, psychiatry, urology, and rehabilitation medicine) requested one evaluation each. Four types of competency evaluations were requested by those services. Requests to determine if patients were competent to return home safely and care for themselves or manage their fiduciary responsibilities accounted for 50% (45 evaluations). Requests to determine if patients were competent to refuse proposed medical treatment constituted 24 (27%) of the evaluations. Requests to determine ifpatients were competent to give informed consent for proposed medical procedures were assessed in 16 (17%) cases. Finally, requests to determine if patients were competent to leave the hospital against medical advice accounted for five (5.5%) cases. The dis61
Competency Evaluation
TABLE I.
Areas of competency at issue in 90 competency evaluations, by admitting service Area of Competency
Admitting Service
Competence to Leave the Hospital Against Medical Advice
Competence to Return Home
Competence to Refuse Treatment
Competence to Give Informed Consent
Total Requests
Medicine
3
35
15
4
57
Onhopedics
0
4
2
4
10
Neurology
I
2
4
2
9
Gynecology
I
I
I
3
6
Surgery
0
2
I
I
4
Miscellaneous
0
I
I
2
4
Total
5
45
24
16
90
TABLE 2. DSM-1I1 diagnoses of 90 patients for whom competency evaluations were requested, by area of competency under evaluation Area of Competency
Diagnosis Organic mental disorder
Competence to Leave the Hospital Against Medical Advice
Competence to RetumHome
Competence to Refuse Treatment
Competence to Give Informed Consent
Total Requests
3
6
38
II
9
3
26
9
5
3
17
I
6
6
2
15
0
3
4
5
12
3
26
Substance abuse
3
Affective disorder
0
Personality disorder Psychotic disorder Adjustment disorder
I
2
3
I
7
Total
8
57
30
20
115
tribution of requests by requesting service is presented in Table 1. No gender bias appeared in the competency evaluation requests. Forty-one males and 49 females were evaluated (X 2=.193,df=2,p=.90). The average age of the evaluated group was 60.7 years. No significant difference existed between the ages of males (59.4 years) and females (61.8 years) (1=.5, df=1, p=.62). No racial bias in the competency requests was apparent. Seventy-five (83%) evaluations involved white patients; nine (l 0%) involved black patients; and six (7%) involved patients of other racial groups. These ratios were comparable to the racial mix of the hospital population for the same four-year span (X 2=.79, df=2, p=.8). 62
Significant differences were found when age was examined in light of the type of competency request (F=4.97, df=3,86, p=.009). The average age of individuals evaluated for competency to leave against medical advice (42.4 years) was some 25 years younger than the average age of the group evaluated for competency to return home (67.7 years). The groups evaluated for informed consent and treatment refusal (53.4 years and 56.2 years, respectively) fell somewhere in the middle. Initial psychiatric opinion regarding competency fell into three categories: undetermined, competent, and incompetent. The competency of 23 patients (26%) was undetermined, while 36 patients (40%) were found incompetent, and 33 PSYCHOSOMATICS
Farnsworth
patients (37%) were found competent. Chart review of the individual cases demonstrated significant shifts in the three groups at the time of discharge or transfer: the competency of 10 patients (II %) remained undetermined; 49 patients (54%) were found to be competent; and 31 patients (34%) were found still to be incompetent. Ten of the 21 patients originally in the undetermined group following the initial interview were later found to be competent, and one was found incompetent. Six individuals initially declared incompetent were later found to be competent. The diagnoses of these 17 individuals included schizophrenia (n=5), delirium (n=7), depression (n=3), and dementia (n=2). A total of 115 DSM-lJI diagnoses were generated by 84 patients. Six patients were found not to meet criteria for a psychiatric disorder. The organic mental disorders of dementia and delirium accounted for 38 (33%) ofthe total diagnoses and comprised 26 (46%) of the diagnoses of patients being evaluated for competency to return home. Substance abuse accounted for 26 (23%) of the 115 diagnoses. Psychotic illnesses were surprisingly rare and accounted for only 12 (l 0%) ofthe total diagnoses. However, five ofthe diagnoses of psychotic illness were made in patients being evaluated for their ability to give informed consent; that diagnosis constituted 25% of diagnoses in these patients. Of the total DSMlJI diagnoses, 24 (21 %) were affective disorders and adjustment disorders; they were distributed widely across the three groups. Table 2 presents the distribution of DSM-lJI diagnoses by the reason for the competency evaluation. The population of referrals for competency evaluations differed from the general population for whom consultations were requested in the overrepresentation of organic mental disorders (OMD) and underrepresentation ofpsychotic and personality disorders. An examination of competency determination by DSM-lJI diagnosis revealed that 26 patients (72%) deemed incompetent carried a diagnosis of dementia or delirium. Organic mental disorders also accounted for eight (33%) diagnoses in the undetermined-competency group. Substance abuse accounted for nearly one-fourth VOLUME 31 • NUMBER 1 • WINTER 1990
of the total diagnoses, but it accounted for only 18% of the diagnoses of the individuals found to be incompetent. However, it accounted for 30% of the diagnoses of the competent group, making it the most frequently encountered diagnosis in that group. Both initial recommendations and eventual dispositions by category of competency question were assessed. There were significant differences in the consultees' responses to the recommendations made by the consultants. A recommendation to transfer a patient to psychiatry or chemical dependency treatment met with the greatest compliance (97%). Compliance with recommendations deemed to be of a medical nature averaged 66%. These recommendations related to the administration of psychotropic medications (69%), obtaining other medical consults (67%), and completing a dementia workup (61%). In contrast, compliance with recommendations regarded as nonmedical averaged only 24%. These recommendations included suggestions for obtaining neuropsychometric evaluations (24% compliance), obtaining Kohlman Evaluation of Living Skills (KELS)IO evaluations (21 % compliance), and establishing guardianships (26% compliance). DISCUSSION This study contained the largest number of patients in a general hospital to be systematically reviewed regarding competency issues. Ninety of 2,340 requests for psychiatric consultation were for competency evaluation, a rate of4%. This rate is comparable to the 6% rate found by Myers and Barren6 in the retrospective portion of their study, which assessed 100 consecutive consultation reports from a two-month period. In the study reported here, the consulting service received approximately one request for competency evaluation every two weeks. Sex and race did not appear to playa role in prompting the competency evaluation requests reviewed in this study. The data suggested that competency evaluations were sought primarily for individuals who refused to follow or who objected to physicians' recommendations for 63
Competency Evaluation
treatment or placement. This observation appeared to be true for all individuals assessed for competency to leave the hospital against medical advice, to return home, or to refuse medical treatments. Usually, the request to evaluate a patient for competency to return home stemmed from a patient's refusal to be placed in a nursing home. In contrast, requests for evaluation of competency to provide informed consent did not occur in the context of a patient's refusing a physician's recommendation but in cases in which the patient appeared to agree with the physician's treatment plan. Other factors may have influenced the decision to obtain a psychiatric evaluation. Two factors that may have played a role in prompting such requests were identified from the chart reviews: a current or past history of a psychotic disorder (schizophrenia or psychotic depression) and the celebrity status of the individual being treated. Six of the evaluations for informed consent were conducted on elderly physicians or local politicians. Physicians requesting competency evaluations may have been scrupulously cautious when treating these individuals and may have used the psychiatric opinion to confirm their own impressions regarding informed consent. Only one-third of the 90 patients evaluated for competency were felt by the consulting psychiatrist to be incompetent. The specific criteria used to determine competency by the consultant were not always clear in this retrospective study. In most respects it appeared that the psychiatrists who conducted the evaluations employed the categories of competence described by Appelbaum and Griss05 without explicitly identifying them. The cognitive component of the mental status exam was emphasized in most cases, and it frequently was accompanied by a Mini-Mental Status Exam. I I In decisions regarding a patient's competency to leave the hospital against medical advice, competency to refuse treatment, or competency to provide informed consent, patients were deemed competent if they understood their clinical condition and appreciated the consequences of their decision. Delirious and demented patients usually were not able to 64
demonstrate adequate understanding to the psychiatrist. Patients seen for competency to return home were generally deemed incompetent ifthey failed to demonstrate adequate functioning in the evaluations conducted by personnel from the occupational therapy or psychology departments and if they demonstrated gross impairment on the cognitive portion of the mental status examination. Many of the patients who refused treatment withheld their consent because they misunderstood or miscommunicated with the treating service. Often, the psychiatrist performing the competency evaluation was able to facilitate communication between the patient and the treatment team and to resolve the conflict. The data did not indicate clearly whether incompetent patients who did not object to treatment or placement were referred for evaluation. The number of individuals who fell into this "incompetent consentor" category is also unknown. In their review of requests for competency assessments, Myers and Barrett6 found that selfdestructive individuals with personality disorders and cognitively impaired individuals were most likely to be the focus of a competency evaluation. Weinstock et al. 7 found that organic brain syndrome was the most frequent diagnosis prompting competency requests in their study. Organic mental disorders and substance abuse were found to be the most common diagnoses of the individuals examined for competence, although the frequency of substance-abuse diagnoses may reflect the emphasis on treating chemical dependency in Minnesota. It may also have reflected some confusion by the consultee regarding the differences between the establishment of a guardianship and civil commitment of chemically dependent individuals. That a significant number of individuals fell into the undetermined competency category following initial evaluation underscores the need for repeated observation and the utilization of assessment tools and other disciplines for sources of information. Data provided by occupational therapy, psychology, and nursing services can be crucial in assessing competence. Repeated examPSYCHOSOMATICS
Farnsworth
inations were useful in identifying medical conditions that rendered an individual temporarily incompetent. Nonstandardized bedside mental status examinations are inadequate to defme the foresight, planning, and execution skills necessary to care for self or property or to manage funds. Repeated examinations were useful in identifying medical conditions that rendered an individual temporarily incompetent. Managing acute delirium, intoxication, or acute psychosis often required the assistance of the consulting psychiatrist to restore the patient to a state of competence. Consultees' compliance with medication and medical evaluation recommendations were similar to rates noted in other published studies,I2,13 but compliance with recommendations regarding competency questions was poor. The timing of a request to evaluate competency during the course of hospitalization may have affected compliance. Discharge against medical advice, informed consent, and treatment refusal issues generally occurred early in hospitalization. Evaluation of competency to return home, in contrast, occurred near the end of hospitalization, usually after treatment was completed and when the treating service was under pressure to make a disposition. Without medical treatment to justify a protracted stay, these services may have opted for a suboptimal solution to the competency issue. The poor compliance may have reflected a resistance by medical staff to perform nonmedical tasks. It also may have reflected the consultant's failure to adequately explain the legal issues and mechanisms necessary in obtaining guardianships.
CONCLUSIONS The relative infrequency of requests to evaluate competency makes it difficult for consultants to become familiar and comfortable with competency evaluations-particularly as they are time consuming, are complex in nature, and require knowledge of the law. However, as the population ages and treatments become more complex, questions of competency of the medically ill will grow, and psychiatrists will be asked to address these difficult issues. Many psychiatrists may feel ill-equipped to address legal issues and believe themselves to be no better at evaluating a patient's capacity to make informed decisions than other physicians. Psychiatrists are regarded as experts in human behavior and are relied upon to make recommendations to medical practitioners and the courts. More formal training in fundamental forensic issues in residency programs will be necessary. Competency questions are difficult to answer. Psychiatrists should be encouraged to involve other mental health specialists in assessing these issues. The consultation-liaison psychiatrist has a role in raising the awareness of competency issues for nonpsychiatrists in the hospital setting. Such increased awareness would promote earlier identification of patients whose competence may be questionable and increase the likelihood of establishing guardianships for patients who are unable to care for themselves.
The author thanks Ms. Sherri Zachariasfor manuscript preparation and Gary D. Tollefson. M.D., PhD.,for valuable suggestions.
References I. Gutheil T, Appelbaum P: Clinical Handbook ofPsychiarry and rhe Law. New York, McGraw Hill, 1982, pp 21~252
2. President's Commission for the Study of Ethical Problems in Medicine and Biomedical Research: Making Health Care Decisions: The Ethical and Legal Implications of Informed Consent in the Patient Practitioner Relationship. Washington, DC, US Government Printing
VOLUME 31 • NUMBER I • WINTER 1990
Office, 1982 3. Roth LH, Meisel A, Lidz CW: Tests of competency to consentto treatment. Aml Psychiarry 134:279-284,1977 4. Drane JH: Competence to give informed consent-a model for making clinical assessments. lAMA 252:925927,1984 5. Appelbaum P, Grisso T: Assessing patients' capacities to consentto treatment. N EnglJ Med 319: 1635-1638, 1988
65
Competency Evaluation
6. Myers B. Barren C: Competency issues in referrals to a consultation-liaison service. Psychosomatics 27:782789.1986 7. Weinstock R. Copelan R. Bagheri A: Competence to give informed consent for medical procedures. Bull Am Acad Psychiatry Law 12:117-125.1984 8. American Psychiatric Association: Diagnostic and Statistical Manual ofMental Disorders. Third Ed. Washington. DC. American Psychiatric Association. 1980 9. SPSS Inc: Statistical Package for the Social Sciences (SPSS). Second Ed. New York. McGraw Hill. 1986 10. Kohlman McGouny L: Kohlman Evaluation of Living
66
Skills: Interim Manual. Second Ed. Seattle. Wash. Kohlman McGourty. 1979 II. Folstein MF. Folstein SE. McHugh PR: Mini-Mental Status Examination. J Psychiatr Res 12: 189-198. 1975 12. Popkin MK. MacKenzie TB. Hall RCW. et a1: Physicians' concordance with consultants' recommendations for psychotropic medication. Arch Gen Psychiatry 36:386-398. 1979 13. Popkin MK. MacKenzie TB. Callies AL: Consultees' concordance with consultants' recommendations for diagnostic action. J Nerv Ment Dis 168:9-12. 1980
PSYCHOSOMATICS
G.
FARNSWORTH. M.D.
This study describes 90 requests for competency evaluation received by a psychiatry consultation service between 1983 and 1986. Most ofthe requests were prompted by a patient's refusal to accept a physician's recommendations regarding treatment or disposition. Delirium and dementia accountedfor the majority ofdiagnoses in the population deemed incompetent. Consultees were more likely to follow recommendations for further medical evaluation than to obtain recommended guardianships, living-skill assessments, or neuropsychometric testing. Guardianships were establishedfor only seven of26 patients deemed incompetent. This study demonstrates the needfor consulting psychiatrists to be aware ofthe forensic issues ofcompetency.
ompetency is a legal construct that has clinical relevance for medical practitioners. Broadly conceptualized, it is an individual's ability to adequately handle his or her personal affairs consonant with personal autonomy-the right to make deliberate decisions within the context of one's life goals and preferences. All adults are presumed competent unless a court adjudicates otherwise. The legal definitions of incompetence are vague and demonstrate considerable variation in terms and basic elements from state to state. Some states apply a single statutory definition of incompetence; others apply an array of definitions for different purposes. Gutheil and Appelbaum l point out that the net result of these various laws is to provide the court with maximum flexibility in determining competence. A recent Presidential commission2 on competency concluded that the core elements of competence included the possession of a set of values and
C
Received September 15. 1988; revised January 30. 1989; accepted February 21.1989. Address reprint requests to Dr. Famswonh. Depanment of Psychiatry. Ramsey Clinic. St. Paul-Ramsey Foundation. 640 Jackson Street. St. Paul. MN 55101. Copyright © 1990 The Academy of Psychosomatic Medicine.
60
goals, the ability to communicate and understand information, and the ability to reason and to deliberate. In the hospital setting, competency issues usually revolve around a patient's consent to, or refusal of, medical treatment and the capacity to safely care for oneself and one's property. Psychiatrists are often asked to render an opinion regarding an individual's competence. A psychiatric finding of incompetence remains only an opinion until it is confirmed by a judicial ruling on the evidence. However, the psychiatric evaluation is often the cornerstone of a judicial determination of incompetence. Attempts to clarify the clinical evaluation of competence have been made,J.-S but competency remains largely an issue determined by an impressionistic collection of bedside mental status examinations. Despite medical practitioners' reliance on psychiatric evaluation ofcompetency, few studies have characterized the population of patients examined for competence. Myers and Barrett6 examined 100 retrospective and 100 prospective consultations for issues related to medical patients' competency to make decisions about treatment. They found that the patients prompting requests for competency evaluations fell into three categories. One group had PSYCHOSOMATICS
Farnsworth
been admitted to the hospital comatose because they had inflicted self-hann; upon recovery, they refused treatment or demanded discharge. A second group comprised elderly patients with cognitive deficits. The third group comprised patients who posed management problems. The most frequent issue prompting requests for competency evaluation was a threat to leave the hospital against medical advice. Weinstock et a1. 7 conducted 30 assessments of competence to give informed consent at a Veterans Administration hospital. They discovered that only patients with organic brain syndromes were found incompetent. They also demonstrated that patients who refused medical treatment were more commonly referred forevaluation of competence than were patients who accepted treatment. Few schizophrenic patients were referred for evaluation, and none were found incompetent. This study describes the outcomes of competency examinations conducted by a psychiatry consultation service in a general hospital. Competency evaluation requests were reviewed, and data concerning the requesting service, specific competency question, Diagnostic and Statistical Manual of Mental Disorders. Third Edition (DSM-llll diagnoses, and recommendations were recorded. The patients' records were then examined to assess compliance with the recommendations and outcomes of the hospitalizations in which the competency question arose. METHODS St. Paul-Ramsey Medical Center is a 272-bed, university-affiliated, teaching hospital that treats both indigent and privately insured individuals. The psychiatry consultation-liaison service received an average of 50 referrals per month between 1983 and 1986; it was staffed by two board-certified psychiatrists. Fourth-yearpsychiatric residents completing an elective in consultation psychiatry, first year residents, and medical students rounded out the service team. All of the psychiatric consultations conducted between 1983 and 1986 were retrospectively reviewed. Referrals specifically for VOLUME31-NUMBER I-WINTER 1990
competency assessment were identified and subjected to a chart review of the hospitalization course that prompted the consultation request. Each consultation report contained a clinical history of the competency issue, social history, past medical history, mental status examination, diagnosis, and a brief discussion of the conclusions and recommendations. Demographic data (age, sex, and race), the service requesting consult, the specific competence question raised, DSM-lll Axis I and II diagnoses, consultant's recommendations, and compliance with recommendations from each consultation were recorded. The retrospective nature ofthis study did not permit a more detailed analysis of the criteria used by the consulting psychiatrist to determine competency. Statistical analysis of the data included cross-tabulation, chi-square, t-test, and analysis of variance using the Statistical Package for the Social Sciences.9 RESULTS The consultation service completed 2,340 assessments between January 1983 and December 1986. Ninety (3.8%) requests were for competency evaluation. The internal medicine department made 57 (63%) requests; orthopedics, neurology, and obstetrics/gynecology requested 25 (28%) evaluations. Surgery requested only four (4.4%) competency evaluations, and four services (radiology, psychiatry, urology, and rehabilitation medicine) requested one evaluation each. Four types of competency evaluations were requested by those services. Requests to determine if patients were competent to return home safely and care for themselves or manage their fiduciary responsibilities accounted for 50% (45 evaluations). Requests to determine if patients were competent to refuse proposed medical treatment constituted 24 (27%) of the evaluations. Requests to determine ifpatients were competent to give informed consent for proposed medical procedures were assessed in 16 (17%) cases. Finally, requests to determine if patients were competent to leave the hospital against medical advice accounted for five (5.5%) cases. The dis61
Competency Evaluation
TABLE I.
Areas of competency at issue in 90 competency evaluations, by admitting service Area of Competency
Admitting Service
Competence to Leave the Hospital Against Medical Advice
Competence to Return Home
Competence to Refuse Treatment
Competence to Give Informed Consent
Total Requests
Medicine
3
35
15
4
57
Onhopedics
0
4
2
4
10
Neurology
I
2
4
2
9
Gynecology
I
I
I
3
6
Surgery
0
2
I
I
4
Miscellaneous
0
I
I
2
4
Total
5
45
24
16
90
TABLE 2. DSM-1I1 diagnoses of 90 patients for whom competency evaluations were requested, by area of competency under evaluation Area of Competency
Diagnosis Organic mental disorder
Competence to Leave the Hospital Against Medical Advice
Competence to RetumHome
Competence to Refuse Treatment
Competence to Give Informed Consent
Total Requests
3
6
38
II
9
3
26
9
5
3
17
I
6
6
2
15
0
3
4
5
12
3
26
Substance abuse
3
Affective disorder
0
Personality disorder Psychotic disorder Adjustment disorder
I
2
3
I
7
Total
8
57
30
20
115
tribution of requests by requesting service is presented in Table 1. No gender bias appeared in the competency evaluation requests. Forty-one males and 49 females were evaluated (X 2=.193,df=2,p=.90). The average age of the evaluated group was 60.7 years. No significant difference existed between the ages of males (59.4 years) and females (61.8 years) (1=.5, df=1, p=.62). No racial bias in the competency requests was apparent. Seventy-five (83%) evaluations involved white patients; nine (l 0%) involved black patients; and six (7%) involved patients of other racial groups. These ratios were comparable to the racial mix of the hospital population for the same four-year span (X 2=.79, df=2, p=.8). 62
Significant differences were found when age was examined in light of the type of competency request (F=4.97, df=3,86, p=.009). The average age of individuals evaluated for competency to leave against medical advice (42.4 years) was some 25 years younger than the average age of the group evaluated for competency to return home (67.7 years). The groups evaluated for informed consent and treatment refusal (53.4 years and 56.2 years, respectively) fell somewhere in the middle. Initial psychiatric opinion regarding competency fell into three categories: undetermined, competent, and incompetent. The competency of 23 patients (26%) was undetermined, while 36 patients (40%) were found incompetent, and 33 PSYCHOSOMATICS
Farnsworth
patients (37%) were found competent. Chart review of the individual cases demonstrated significant shifts in the three groups at the time of discharge or transfer: the competency of 10 patients (II %) remained undetermined; 49 patients (54%) were found to be competent; and 31 patients (34%) were found still to be incompetent. Ten of the 21 patients originally in the undetermined group following the initial interview were later found to be competent, and one was found incompetent. Six individuals initially declared incompetent were later found to be competent. The diagnoses of these 17 individuals included schizophrenia (n=5), delirium (n=7), depression (n=3), and dementia (n=2). A total of 115 DSM-lJI diagnoses were generated by 84 patients. Six patients were found not to meet criteria for a psychiatric disorder. The organic mental disorders of dementia and delirium accounted for 38 (33%) ofthe total diagnoses and comprised 26 (46%) of the diagnoses of patients being evaluated for competency to return home. Substance abuse accounted for 26 (23%) of the 115 diagnoses. Psychotic illnesses were surprisingly rare and accounted for only 12 (l 0%) ofthe total diagnoses. However, five ofthe diagnoses of psychotic illness were made in patients being evaluated for their ability to give informed consent; that diagnosis constituted 25% of diagnoses in these patients. Of the total DSMlJI diagnoses, 24 (21 %) were affective disorders and adjustment disorders; they were distributed widely across the three groups. Table 2 presents the distribution of DSM-lJI diagnoses by the reason for the competency evaluation. The population of referrals for competency evaluations differed from the general population for whom consultations were requested in the overrepresentation of organic mental disorders (OMD) and underrepresentation ofpsychotic and personality disorders. An examination of competency determination by DSM-lJI diagnosis revealed that 26 patients (72%) deemed incompetent carried a diagnosis of dementia or delirium. Organic mental disorders also accounted for eight (33%) diagnoses in the undetermined-competency group. Substance abuse accounted for nearly one-fourth VOLUME 31 • NUMBER 1 • WINTER 1990
of the total diagnoses, but it accounted for only 18% of the diagnoses of the individuals found to be incompetent. However, it accounted for 30% of the diagnoses of the competent group, making it the most frequently encountered diagnosis in that group. Both initial recommendations and eventual dispositions by category of competency question were assessed. There were significant differences in the consultees' responses to the recommendations made by the consultants. A recommendation to transfer a patient to psychiatry or chemical dependency treatment met with the greatest compliance (97%). Compliance with recommendations deemed to be of a medical nature averaged 66%. These recommendations related to the administration of psychotropic medications (69%), obtaining other medical consults (67%), and completing a dementia workup (61%). In contrast, compliance with recommendations regarded as nonmedical averaged only 24%. These recommendations included suggestions for obtaining neuropsychometric evaluations (24% compliance), obtaining Kohlman Evaluation of Living Skills (KELS)IO evaluations (21 % compliance), and establishing guardianships (26% compliance). DISCUSSION This study contained the largest number of patients in a general hospital to be systematically reviewed regarding competency issues. Ninety of 2,340 requests for psychiatric consultation were for competency evaluation, a rate of4%. This rate is comparable to the 6% rate found by Myers and Barren6 in the retrospective portion of their study, which assessed 100 consecutive consultation reports from a two-month period. In the study reported here, the consulting service received approximately one request for competency evaluation every two weeks. Sex and race did not appear to playa role in prompting the competency evaluation requests reviewed in this study. The data suggested that competency evaluations were sought primarily for individuals who refused to follow or who objected to physicians' recommendations for 63
Competency Evaluation
treatment or placement. This observation appeared to be true for all individuals assessed for competency to leave the hospital against medical advice, to return home, or to refuse medical treatments. Usually, the request to evaluate a patient for competency to return home stemmed from a patient's refusal to be placed in a nursing home. In contrast, requests for evaluation of competency to provide informed consent did not occur in the context of a patient's refusing a physician's recommendation but in cases in which the patient appeared to agree with the physician's treatment plan. Other factors may have influenced the decision to obtain a psychiatric evaluation. Two factors that may have played a role in prompting such requests were identified from the chart reviews: a current or past history of a psychotic disorder (schizophrenia or psychotic depression) and the celebrity status of the individual being treated. Six of the evaluations for informed consent were conducted on elderly physicians or local politicians. Physicians requesting competency evaluations may have been scrupulously cautious when treating these individuals and may have used the psychiatric opinion to confirm their own impressions regarding informed consent. Only one-third of the 90 patients evaluated for competency were felt by the consulting psychiatrist to be incompetent. The specific criteria used to determine competency by the consultant were not always clear in this retrospective study. In most respects it appeared that the psychiatrists who conducted the evaluations employed the categories of competence described by Appelbaum and Griss05 without explicitly identifying them. The cognitive component of the mental status exam was emphasized in most cases, and it frequently was accompanied by a Mini-Mental Status Exam. I I In decisions regarding a patient's competency to leave the hospital against medical advice, competency to refuse treatment, or competency to provide informed consent, patients were deemed competent if they understood their clinical condition and appreciated the consequences of their decision. Delirious and demented patients usually were not able to 64
demonstrate adequate understanding to the psychiatrist. Patients seen for competency to return home were generally deemed incompetent ifthey failed to demonstrate adequate functioning in the evaluations conducted by personnel from the occupational therapy or psychology departments and if they demonstrated gross impairment on the cognitive portion of the mental status examination. Many of the patients who refused treatment withheld their consent because they misunderstood or miscommunicated with the treating service. Often, the psychiatrist performing the competency evaluation was able to facilitate communication between the patient and the treatment team and to resolve the conflict. The data did not indicate clearly whether incompetent patients who did not object to treatment or placement were referred for evaluation. The number of individuals who fell into this "incompetent consentor" category is also unknown. In their review of requests for competency assessments, Myers and Barrett6 found that selfdestructive individuals with personality disorders and cognitively impaired individuals were most likely to be the focus of a competency evaluation. Weinstock et al. 7 found that organic brain syndrome was the most frequent diagnosis prompting competency requests in their study. Organic mental disorders and substance abuse were found to be the most common diagnoses of the individuals examined for competence, although the frequency of substance-abuse diagnoses may reflect the emphasis on treating chemical dependency in Minnesota. It may also have reflected some confusion by the consultee regarding the differences between the establishment of a guardianship and civil commitment of chemically dependent individuals. That a significant number of individuals fell into the undetermined competency category following initial evaluation underscores the need for repeated observation and the utilization of assessment tools and other disciplines for sources of information. Data provided by occupational therapy, psychology, and nursing services can be crucial in assessing competence. Repeated examPSYCHOSOMATICS
Farnsworth
inations were useful in identifying medical conditions that rendered an individual temporarily incompetent. Nonstandardized bedside mental status examinations are inadequate to defme the foresight, planning, and execution skills necessary to care for self or property or to manage funds. Repeated examinations were useful in identifying medical conditions that rendered an individual temporarily incompetent. Managing acute delirium, intoxication, or acute psychosis often required the assistance of the consulting psychiatrist to restore the patient to a state of competence. Consultees' compliance with medication and medical evaluation recommendations were similar to rates noted in other published studies,I2,13 but compliance with recommendations regarding competency questions was poor. The timing of a request to evaluate competency during the course of hospitalization may have affected compliance. Discharge against medical advice, informed consent, and treatment refusal issues generally occurred early in hospitalization. Evaluation of competency to return home, in contrast, occurred near the end of hospitalization, usually after treatment was completed and when the treating service was under pressure to make a disposition. Without medical treatment to justify a protracted stay, these services may have opted for a suboptimal solution to the competency issue. The poor compliance may have reflected a resistance by medical staff to perform nonmedical tasks. It also may have reflected the consultant's failure to adequately explain the legal issues and mechanisms necessary in obtaining guardianships.
CONCLUSIONS The relative infrequency of requests to evaluate competency makes it difficult for consultants to become familiar and comfortable with competency evaluations-particularly as they are time consuming, are complex in nature, and require knowledge of the law. However, as the population ages and treatments become more complex, questions of competency of the medically ill will grow, and psychiatrists will be asked to address these difficult issues. Many psychiatrists may feel ill-equipped to address legal issues and believe themselves to be no better at evaluating a patient's capacity to make informed decisions than other physicians. Psychiatrists are regarded as experts in human behavior and are relied upon to make recommendations to medical practitioners and the courts. More formal training in fundamental forensic issues in residency programs will be necessary. Competency questions are difficult to answer. Psychiatrists should be encouraged to involve other mental health specialists in assessing these issues. The consultation-liaison psychiatrist has a role in raising the awareness of competency issues for nonpsychiatrists in the hospital setting. Such increased awareness would promote earlier identification of patients whose competence may be questionable and increase the likelihood of establishing guardianships for patients who are unable to care for themselves.
The author thanks Ms. Sherri Zachariasfor manuscript preparation and Gary D. Tollefson. M.D., PhD.,for valuable suggestions.
References I. Gutheil T, Appelbaum P: Clinical Handbook ofPsychiarry and rhe Law. New York, McGraw Hill, 1982, pp 21~252
2. President's Commission for the Study of Ethical Problems in Medicine and Biomedical Research: Making Health Care Decisions: The Ethical and Legal Implications of Informed Consent in the Patient Practitioner Relationship. Washington, DC, US Government Printing
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Office, 1982 3. Roth LH, Meisel A, Lidz CW: Tests of competency to consentto treatment. Aml Psychiarry 134:279-284,1977 4. Drane JH: Competence to give informed consent-a model for making clinical assessments. lAMA 252:925927,1984 5. Appelbaum P, Grisso T: Assessing patients' capacities to consentto treatment. N EnglJ Med 319: 1635-1638, 1988
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6. Myers B. Barren C: Competency issues in referrals to a consultation-liaison service. Psychosomatics 27:782789.1986 7. Weinstock R. Copelan R. Bagheri A: Competence to give informed consent for medical procedures. Bull Am Acad Psychiatry Law 12:117-125.1984 8. American Psychiatric Association: Diagnostic and Statistical Manual ofMental Disorders. Third Ed. Washington. DC. American Psychiatric Association. 1980 9. SPSS Inc: Statistical Package for the Social Sciences (SPSS). Second Ed. New York. McGraw Hill. 1986 10. Kohlman McGouny L: Kohlman Evaluation of Living
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Skills: Interim Manual. Second Ed. Seattle. Wash. Kohlman McGourty. 1979 II. Folstein MF. Folstein SE. McHugh PR: Mini-Mental Status Examination. J Psychiatr Res 12: 189-198. 1975 12. Popkin MK. MacKenzie TB. Hall RCW. et a1: Physicians' concordance with consultants' recommendations for psychotropic medication. Arch Gen Psychiatry 36:386-398. 1979 13. Popkin MK. MacKenzie TB. Callies AL: Consultees' concordance with consultants' recommendations for diagnostic action. J Nerv Ment Dis 168:9-12. 1980
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