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When Do Physicians Request Competency Evaluations?
When Do Physicians Request Competency Evaluations? H. MEBANE. M.D. HARRY B. RAUCH. M.D.
ANDREW
Fifty consecutive requests for competency evaluations were reviewed retrospectively to determine the characteristics ofthe request. The data from this study suggest that requests for competency are seen within certain discrete. demographically varied categories; are often urgent; are usually not the result ofa functional Axis I disorder; are more common for patients with previously diagnosed organic mental disorders.. are often stimulated by patients who do not participate in diagnostic or treatment plans or by patients who threaten to leave against medical advice; are less frequently concerned with informed consent; and are more common in younger patients. Overall, patients are as likely to be judged competent as incompetent. Elements ofthe mental status examination that are crucial to the assessment of competency are delineated.
sychiatrists are asked with growing frequency to assess competency in a variety of medical settings. Many of the requests for competency evaluation arise in emotionally charged situations prompted by patients who refuse treatment or threaten to leave treatment against medical advice (AMA). Although the ethical, legal. and philosophical issues involved in competency have been addressed in detail. l -6 few investigators have examined the characteristics of the consultation request for competency evaluation or the demographics of the patient population whose competency is in question. Weinstock et a1. 7 noted that many requests for competency evaluations are inappropriate. In this study, we examine requests for competency evaluation, de-
P
Received May 10. 1988; accepted October 24. 1988. From the Department ofPsychiatry•OchsnerClinic and Alton Ochsner Medical Foundation. New Orleans. Louisiana; and Clark Air Force Base. Philippines. Address reprint requests to Dr. Mebane. Ochsner Clinic. 1516 Jefferson Highway. New Orleans. LA 70121. Copyright © 1990 The Academy of Psychosomatic Medicine.
40
scribe the kinds of patients referred for evaluation and the contexts of the requests. and examine the outcome of these consultations.
METHODS Psychiatric consultation records from a major academic military medical center from 1981 through 1984 were retrospectively screened. Because many active-duty military personnel receive mandatory assessments for competency regarding "pay and records" (the ability to manage their own finances and enter into contracts). only patients who were military-personnel dependents or were retired military personnel were selected for this study. Fifty consecutive charts in which the referring physician had specifically requested an evaluation of competency were analyzed. For each record. basic demographics. the expressed urgency of the request (whether it was an emergency. needed that day. needed within 72 hours. or routine), and diagnoses on Axis I. II. or III of the Diagnostic and Statistical Manual of PSYCHOSOMATICS
Mebane and Rauch
Mental Disorders. Third Edition (DSM-IlJ)8 were analyzed. When possible, the reason for the evaluation was inferred directly from the wording of the physician's request. For example, a request might read, "The patient is refusing surgery; please evaluate competency." When the reason for the request was stated less explicitly ("Please evaluate competency"), a psychiatry resident's description of the present illness provided the information needed to elucidate the context that generated psychiatric consultation. Charts that indicated the referring physician's impression of whether the patient was competent or incompetent were also selected. This information was often contained in the request for consultation or, if not, it was included in the resident's write-up. The data were then tabulated. A chi-square analysis was performed to compare category and diagnosis, diagnosis and outcome, and outcome and category relationships. The initial psychiatric evaluations were performed by residents, and all patients were seen and interviewed by a staff psychiatrist. During this four-year period, four board-certified psychiatrists were responsible for the final assessment of competency. Our approach to determining competency was clinical and pragmatic. The criteria establishing incompetency required that the patient be impaired in one of three areas: attention, learning (recent memory), or judgment. These criteria were augmented by various cognitive tests (summarized by Roth et al.s) establishing "thresholds" of competency. There are five thresholds, or degrees, of competency that include making a choice; making a choice that could have a reasonable outcome; making a choice based on rational reasons; having the ability to understand; and having actual understanding. The delirious patient with markedly altered attention is clearly not capable of understanding. Individuals with alcohol amnestic syndrome may have perfectly adequate attention, but they are unable to retain the information over time; because they are unable to learn, they can recall neither their treatment options nor their own deVOLUME 31 • NUMBER 1 • WINTER 1990
cisions. Judgment might be impaired by intense affect (for example, a patient with cancer phobia may experience overwhelming anxiety); by delusions or unusual beliefs; or by perceptual disturbances (for example, hallucinations). Therefore, to be considered incompetent, a patient must have been clinically impaired in at least learning, recent memory, or judgment. In addition, if the patient is found to have impaired judgment, for instance, because of the patient's intense affect, unusual belief, or perceptual disturbance, the impairment must have directly interfered with the specific decision-making process for him or her to be considered incompetent. Thus, obtaining informed consent from a schizophrenic patient with chronic, benign auditory hallucinations, such as mumbling or music, involves different aspects of competency than obtaining informed consent from a patient who believes that voices are telling him or her, "The doctors are going to kill you for your blood." These assessments were complemented with rigorous bedside cognitive examinations, a comprehensive history, and mental status examinations. In all cases reviewed, the patients' attention, learning, and remote memory functions were tested repetitively, over hours and days, prior to diagnosis.
RESULTS Requests for competency evaluation were received from a wide variety of hospital services. General internal medicine made the most requests (54%), and neurology made 16% of requests. The remaining 30% of requests were divided evenly between specialties. The mean age ofpatients for whom competency evaluations were requested was 55 years (range, 20 to 85 years). Fifty percent of requests were made for male patients. Competency evaluations fell into several very distinct categories: evaluations to determine whether the patient needed to have a guardian appointed (34%); to determine whether the patient could give informed consent (24%); to determine whether a patient who threatened to leave against medical advice was competent to make 41
Requests for Competency Evaluations
TABLE •• Reason for competency evaluation request by diagnosis
or patient
Diagnosis Delirium or Dementia
One or More Axis. Diagnoses"
Ak:ohol Abuse or Dependence
Axis. Diagnosis Other ThanOMD"
,.
%
,.
%
,.
%
,.
%
Plans to leave against medical advice (n=8)
7
88
2
25
2
25
2
25
Refused diagnostic or treatment procedures (n=8)
6
75
3
38
13
3
38
Need for guardianship (n= 17)
16
94
16
94
7
41
0
0
8
66
7
58
2
18
0
0
I 38
20 76
I
20
29
58
0 12
0 24
0 5
10
Reason for Competency Request
Ability to give informed consent (n=12) OtherC (n=5) Total (n=50)
0
"Many patients had more than one Axis I diagnosis. borganic mental disorder 'This category included questions of mandatory retirement (n= I); fitness to adopt (n= I); possible job impairment (n=2); and competency to compose a will (n= I).
that decision (16%); and to detennine whether a patient was competent to refuse treatment or diagnostic procedures (16%). Other unrelated issues constituted the remaining 10% of requests. One patient was evaluated to detennine the possibility of mandatory retirement; one for fitness to adopt; two for possible impainnent on the job; and one for competency to compose a will. Table I summarizes the types of requests and characteristics of patient groups for which requests to evaluate competency were made. Most requests for competency assessment were considered to be urgent by the requesting physician. More than one-half (58%) were identified as emergencies or were asked to be completed on the same day as the request, as soon as possible, or within 72 hours of the request. Overall, roughly equal proportions of patients were found competent and incompetent (46% and 54%, respectively). However, patients were more likely to be found incompetent and to be psychiatrically committed if they threatened to leave against medical advice. Of eight patients assessed for this reason, only one was found competent (X~.5, df=l, p<.03). Patients who were being evaluated for possible guardianship were also more likely to be found incompetent. Only two of 17 patients in this category were 42
found to be competent (X2=9.94, df=l, p<.OO2). In contrast, patients were largely found to be competent if they refused treatment or diagnostic procedures. Seven of eight patients assessed in this category were found to be competent (X 2=4.5, df=l, p<.03). Patients being evaluated for competency to give infonned consent were largely found to be competent. Only three of 12 patients were found to be incompetent, but the proportion was not significant (X2=3.0, df=l). Seventy-four percent of patients received more than one Axis I diagnosis. Organic mental disorders (OMD) predominated; 58% ofthe sample were diagnosed with delirium or dementia. Twenty-four percent received a diagnosis of alcohol abuse or dependence. Sixty-six percent of patients diagnosed with delirium or dementia were found incompetent (X 2=6.27, df= 1, p<.03). Ninety-four percent of patients whose need for guardianship was evaluated received a diagnosis of delirium, dementia, or both, as did 58% of patients evaluated for their competence to give infonned consent. Of the 12 patients who received a diagnosis of alcohol abuse or dependence, 75% were judged incompetent; eight of these patients had coexisting delirium or dementia. Twenty-five percent of patients threatening to leave AMA and 41 % of patients possibly rePSYCHOSOMATICS
Mebane and Rauch
TABLE 2.
Outcome 01 competency evaluation by diagnosis of patient
DIagnosis
Number of Patients"
Outcome Competent
Incompetent
Organic mental disorders (except alcohol related)
33
II
22
Alcohol-related disorders (abuse or dependence)
12
3
9
Affective disorders depression dysthymia Adjustment disorder depressed mood mixed features
2
Ib
I
0
0
I
2
0
0
I
Axis II disorder
0
I
Schizophrenia
I
0
Diagnosis deferred No diagnosis or V-code diagnosis
I'
13
0
I
13
0
"Many patients had more than one Axis I diagnosis. bActuai diagnosis was borderline personality disorder (adjustment disorder with mixed emotional features and suicide attempt). 'Patient eloped prior to fuIl diagnostic work-up.
quiring guardianship received the diagnosis of alcohol abuse or dependence. Table I summarizes reasons for competency-evaluation request by diagnosis of patients. Overall, non-OMD (functional) Axis I diagnoses were uncommon. Only 10% of patients received diagnoses of functional mental disorders, and all diagnoses were either for major or minor depression (see Table 2). All of the patients with Axis I diagnoses were evaulated for one of two categories-threatening to leave against medical advice (25%) or refusing diagnostic or treatment procedures (38%) (see Table I). No patient received a diagnosis offunctional psychosis; one patient received a secondary diagnosis of schizophrenia, residual type. One patient received an Axis II diagnosis. One patient whose medical work-up was insufficient to differentiate an organic mental disorder from a functional psychosis was judged to be incompetent. Twenty-six percent of all patients had no diagnosis or a DSM-llI V-code diagnosis (life circumstance problem); all of them were judged competent (Table 2). Although the mean age of the sample was 55 years, patients who were assessed to determine if VOLUME 31' NUMBER I • WINTER \990
they required a guardian were significantly older (mean age, 66 years). If we exclude patients evaluated for guardianship, the mean age drops considerably, to 50 years. The average age of the patients referred to determine competence to give informed consent was 48 years; the mean age of patients referred for assessment because they were threatening to leave against medical advice was 52 years; and the mean age of patients referred for assessment because they were refusing diagnostic or treatment procedures was 54 years. The sex ratios, although they were equally distributed over the entire sample, were unevenly distributed in some referral categories. The ratio of men to women who threatened to leave against medical advice was 6:2; the ratio of men to women referred for refusing treatment was 3:5; and the ratio of men to women referred for guardianship was 6: II. Only in the group referred to determine competency to give informed consent was the ratio of males to females equal (6:6). DISCUSSION Strictly speaking, the term competency is of legal rather than psychiatric origin and denotes an 43
Requests for Competency Evaluations
individual's ability to carry on personal business. When used psychiatrically, it refers to an individual's mental capacity to process data and draw conclusions.9 While legal competence is determined by judgment of the courts utilizing statutes and expert testimony (usually from a psychiatrist), psychiatric competence is determined in a bedside setting by the judgment of an experienced clinician utilizing clinical tools like the mental status examination. In both settings. the test of competency varies according to context. The crucial question is not whether an individual is competent in general, but whether he or she is competent to do a particular thing. It is very possible that an individual considered incompetent to conduct financial and legal matters, such as making a will or buying a home, would be found competent to give informed consent for surgery. Drane 10 has suggested that clinicians use a scale that applies increasingly stringent standards of competence as the consequences of the patient's decisions entail more risk to the patient.
While this study was remarkable for demonstrating the extent of psychopathology in the general hospital setting, over-inclusiveness greatly limited the description of both the kinds of patients referred for competency evaluations and the settings in which they are referred. Both the Weinstock et at. II and the Strain et a1.'2 studies alluded to treatment refusal (or refusal to sign a consent form) as a common precipitant to the request for a competency evaluation. Our study shows, however, that even though informed consent might have been the central issue for the consulting psychiatrists, only one-quarter of the referring physicians specifically requested assessment for informed consent. Patients who threatened to leave against medical advice and patients who refused to undergo diagnostic or treatment procedures precipitate nearly one-third of the requests for competency evaluation. Myers and Barrett l3 demonstrated how important refusing treatment and threatening to leave against medical advice are in generating
In genentl. to be considered competent, an indi-
requests for competency evaluation. They retro-
vidual needs only to comprehend the nature ofthe specific conduct in question and to understand its quality and consequences. Two previous attempts to examine the population of patients referred for competency assessment have lumped all requests for competency under the category of informed consent. Weinstock et a1.,'1 on a Veterans Administration psychiatric consultation service, prospectively screened all requests for competence for informed consent. For a request to be realized, a procedure must have been anticipated. Thirty male patients were referred for competency evaluation; three patients were not evaluated because the requests were considered inappropriate (no medical procedure was planned). Ten patients were judged to be incompetent, and all received a diagnosis of an organic brain syndrome. Strain et a1. 12 analyzed legally mandated mental status assessments whereby all patients who seemed not to understand the meaning of consent were referred for psychiatric interviews. Routine requests were made for competency evaluation prior to surgery and procedures.
spectively examined 100 consultation requests and found requests for competency assessment were the initial cause of referral in six cases. Of the six, four patients had threatened to leave against medical advice, and one patient had refused treatment. Only one request was made to determine competency to make informed consent. Myers and Barrett also prospectively examined 100 charts and found nine charts in which questions of competency initiated the consultation request. Five of the nine patients had threatened to leave against medical advice, and four patients had refused treatment. In our study, patients who threatened to leave the hospital against medical advice and patients who refused diagnostic or treatment procedures differed diagnostically and demographically. Patients who threatened to leave against medical advice were usually men, and they were largely found to be incompetent, whereas patients who refused diagnostic or treatment procedures were more commonly women who were largely found to be competent. The finding that
44
PSYCHOSOMATICS
Mebane and Rauch
most patients who refused treatment were competent to do so is consistent with another study that was conducted by Appelbaum and Roth. 14 They found that "the vast majority of those refusing treatment would not be considered mentally ill" (p. 1296). Other investigators ls •16 have commented on the efficacy of physician involvement in reversing the patient's decision to refuse treatment and in mediating when patients threaten to leave against medical advice. However, within these categories, over 33% of patients with Axis I diagnoses displayed eminently treatable psychiatric illness. In addition, the presence of organic mental disorders was lower and seemed to be unrelated to the ultimate decision regarding competency. These are the most dramatic and urgent situations in which psychiatrists are asked to assess competency, and they have an opportunity to make critical and crucial therapeutic interventions. In our study, the consultee and consultant agreed most often when the question of a patient's competence or incompetence involved guardianship. Most patients in this category had experienced long-term, moderate to severe cognitive deterioration that was recognized by family and friends. Many patients had already received a diagnosis of dementia, and involving the courts was considered necessary to long-term care. An unanticipated finding was the high rate of alcohol abuse or dependence among patients referred to determine if guardianships were required. In this and other categories, alcoholism seemed to amplify the possibility that a patient would be judged incompetent. Concordance between consultant and consultee about outcome of competency requests when patients threatened to leave against medical advice was also high. In seven of eight cases, the patients were felt to be dangerous to themselves, and commitment proceedings were initiated to ensure proper psychiatric care. Physicians who requested consultation usually considered this category to be a psychiatric emergency. Low concordance was seen in all other categories. When competence to give informed consent was questioned, many patients had a history VOLUME 31 -NUMBER I-WINTER 1990
of severe and chronic illness, including cerebrovascular accidents. Some patients had received a diagnosis of dementia. The requests for competency evaluation seemed to be generated by a genuine apprehension about the patient's ability to understand. compounded by a lack of family involvement in the decision-making process. When the question of competence involved patients who were refusing diagnostic or treatment procedures, concordance between consultant and consultee was also low. Rather than being generated by a true concern for the patient's ability to participate in decision making, the consultations seemed to be generated by the primary physician's frustration and anger. While patients who refused diagnostic or treatment procedures were not as physically ill as those evaluated for competence to give informed consent, patients who refused diagnostic or treatment procedures had the highest rate of affective disorders. In these cases, consulting physicians felt that the changes in affect (depression, anergy, indecision) were directly responsible for the patient's refusals. For the consulting psychiatrist, the problem of competency arises much more frequently in patients who have previously undiagnosed delirium or dementia 17-in other words, in patients the psychiatrist has been asked to see ostensibly for other reasons. In fact, it is often the consulting psychiatrist who alerts the referring physician to possible informed-consent issues. The conclusion that a particular patient is not competent to participate in informed-consent or treatment decisions is generally not appreciated by the surgeon who has scheduled operating room time or by the cardiologist who is eager to perform coronary angiography. In the clinical arena, this type of dilemma is most often circumvented by consulting with the family and obtaining their permission. However, when the family is not available, the psychiatrist may find himself or herself in a most unenviable position. For this reason, the psychiatrist must be able to furnish informed answers or directions based upon a limited knowledge of the law and of clinical ethics. Unless an awareness of why and when a 45
Requests for Competency Evaluations
physician requests a competency evaluation is balanced with an organized approach to assessment, it is unlikely that the best interests of the patient will be served. Nor is it likely that the psychiatrist will be asked to consult again. The authors thank M. Sackettfor editing and administrative support, MR. Fragala, COL.
USAF, MC (M.D.), M.G. Wise, LTC, USAF, MC (M.D.), and P.P. Roy-Byrne. M.D.Jor editorial assistance and guidance, and the medical editorial department ofAlton Ochsner Medical Foundation. This work was presented at the 40th Institute on Hospital and Community Psychiatry held October 22-27.1988, in New Orleans.
References I. Abernethy V: Compassion, control, and decisions about competency. Am 1 Psychiatry 141 :5~, 1984
Macmillan, 1982 10. Drane IF: Competency to give an informed consent.
2. Sadoff R: Patient rights vs patient needs: who decides? 1 Clin Psychiatry 44:27-32, 1983 3. Sherlock R: Competency to consent to medical care: toward a general view. Gen Hosp Psychiatry 6:71-76, 1984 4. Groves J, Vaccarino J: Legal aspects of consultation, in Hacken T, Cassem N (eds): MassachusetlsGeneral Hospital Handbook of General Hospital Psychiatry. St. Louis, Mosby, 1978. pp 546-561 5. Roth L, Meisel A, Lidz C: Tests ofcompetency to consent to treatment. Aml Psychiatry 134:279-284, 1977 6. Fogel B, Mills M, Landen J: Legal aspects of the treatment of delirium. Hosp Community Psychiatry 37:154-158, 1986 7. Weinstock R, Copelan R, Bagheri A: Physicians' confusion as demonstrated by competency requests. 1 Forensic Sci 30:37-43,1985 8. American Psychiatric Association: Diagnostic andStatistical Manual ofMental Disorders. Third Ed. Washington, DC, American Psychiatric Association, 1980 9. Jonsen AR, Siegler M (eds): Clinical Ethics. New York,
lAMA 252:925-927,1984 II. Weinstock R. Copelan R. Bagheri A: Competence to give informed consent for medical procedures. Bull Am Acad Psychiatry Law 12:117-125. 1984
46
12. Strain J, Taintor Z, Gise L, et aI: Informed consent-mandating the consultation. Gen Hosp Psychiatry 7:228-233, 1985 13. Myers B. Barren C: Competency issues in referrals to a consultation-liaison service. Psychosomatics 27:782789, 1986 14. Appelbaum P, Roth L: Patients who refuse treatment in medical hospitals. lAMA 250:1296-1301,1983 15. Albert H, Kornfeld D: The threat to sign out against medical advice. Ann Intern Med79:888-89I, 1973 16. Himmelhock J, Davis N, Tucker G, et aI: Buning heads: patients who refuse necessary procedures. Psychiatry Medl:241-249,1970 17. Folks D, Ford C: Psychiatric disorders in geriatric medicaVsurgical patients: part I. Report of 195 consecutive consultations. South Med 1 78:239-241, 1985
PSYCHOSOMATICS
ANDREW
Fifty consecutive requests for competency evaluations were reviewed retrospectively to determine the characteristics ofthe request. The data from this study suggest that requests for competency are seen within certain discrete. demographically varied categories; are often urgent; are usually not the result ofa functional Axis I disorder; are more common for patients with previously diagnosed organic mental disorders.. are often stimulated by patients who do not participate in diagnostic or treatment plans or by patients who threaten to leave against medical advice; are less frequently concerned with informed consent; and are more common in younger patients. Overall, patients are as likely to be judged competent as incompetent. Elements ofthe mental status examination that are crucial to the assessment of competency are delineated.
sychiatrists are asked with growing frequency to assess competency in a variety of medical settings. Many of the requests for competency evaluation arise in emotionally charged situations prompted by patients who refuse treatment or threaten to leave treatment against medical advice (AMA). Although the ethical, legal. and philosophical issues involved in competency have been addressed in detail. l -6 few investigators have examined the characteristics of the consultation request for competency evaluation or the demographics of the patient population whose competency is in question. Weinstock et a1. 7 noted that many requests for competency evaluations are inappropriate. In this study, we examine requests for competency evaluation, de-
P
Received May 10. 1988; accepted October 24. 1988. From the Department ofPsychiatry•OchsnerClinic and Alton Ochsner Medical Foundation. New Orleans. Louisiana; and Clark Air Force Base. Philippines. Address reprint requests to Dr. Mebane. Ochsner Clinic. 1516 Jefferson Highway. New Orleans. LA 70121. Copyright © 1990 The Academy of Psychosomatic Medicine.
40
scribe the kinds of patients referred for evaluation and the contexts of the requests. and examine the outcome of these consultations.
METHODS Psychiatric consultation records from a major academic military medical center from 1981 through 1984 were retrospectively screened. Because many active-duty military personnel receive mandatory assessments for competency regarding "pay and records" (the ability to manage their own finances and enter into contracts). only patients who were military-personnel dependents or were retired military personnel were selected for this study. Fifty consecutive charts in which the referring physician had specifically requested an evaluation of competency were analyzed. For each record. basic demographics. the expressed urgency of the request (whether it was an emergency. needed that day. needed within 72 hours. or routine), and diagnoses on Axis I. II. or III of the Diagnostic and Statistical Manual of PSYCHOSOMATICS
Mebane and Rauch
Mental Disorders. Third Edition (DSM-IlJ)8 were analyzed. When possible, the reason for the evaluation was inferred directly from the wording of the physician's request. For example, a request might read, "The patient is refusing surgery; please evaluate competency." When the reason for the request was stated less explicitly ("Please evaluate competency"), a psychiatry resident's description of the present illness provided the information needed to elucidate the context that generated psychiatric consultation. Charts that indicated the referring physician's impression of whether the patient was competent or incompetent were also selected. This information was often contained in the request for consultation or, if not, it was included in the resident's write-up. The data were then tabulated. A chi-square analysis was performed to compare category and diagnosis, diagnosis and outcome, and outcome and category relationships. The initial psychiatric evaluations were performed by residents, and all patients were seen and interviewed by a staff psychiatrist. During this four-year period, four board-certified psychiatrists were responsible for the final assessment of competency. Our approach to determining competency was clinical and pragmatic. The criteria establishing incompetency required that the patient be impaired in one of three areas: attention, learning (recent memory), or judgment. These criteria were augmented by various cognitive tests (summarized by Roth et al.s) establishing "thresholds" of competency. There are five thresholds, or degrees, of competency that include making a choice; making a choice that could have a reasonable outcome; making a choice based on rational reasons; having the ability to understand; and having actual understanding. The delirious patient with markedly altered attention is clearly not capable of understanding. Individuals with alcohol amnestic syndrome may have perfectly adequate attention, but they are unable to retain the information over time; because they are unable to learn, they can recall neither their treatment options nor their own deVOLUME 31 • NUMBER 1 • WINTER 1990
cisions. Judgment might be impaired by intense affect (for example, a patient with cancer phobia may experience overwhelming anxiety); by delusions or unusual beliefs; or by perceptual disturbances (for example, hallucinations). Therefore, to be considered incompetent, a patient must have been clinically impaired in at least learning, recent memory, or judgment. In addition, if the patient is found to have impaired judgment, for instance, because of the patient's intense affect, unusual belief, or perceptual disturbance, the impairment must have directly interfered with the specific decision-making process for him or her to be considered incompetent. Thus, obtaining informed consent from a schizophrenic patient with chronic, benign auditory hallucinations, such as mumbling or music, involves different aspects of competency than obtaining informed consent from a patient who believes that voices are telling him or her, "The doctors are going to kill you for your blood." These assessments were complemented with rigorous bedside cognitive examinations, a comprehensive history, and mental status examinations. In all cases reviewed, the patients' attention, learning, and remote memory functions were tested repetitively, over hours and days, prior to diagnosis.
RESULTS Requests for competency evaluation were received from a wide variety of hospital services. General internal medicine made the most requests (54%), and neurology made 16% of requests. The remaining 30% of requests were divided evenly between specialties. The mean age ofpatients for whom competency evaluations were requested was 55 years (range, 20 to 85 years). Fifty percent of requests were made for male patients. Competency evaluations fell into several very distinct categories: evaluations to determine whether the patient needed to have a guardian appointed (34%); to determine whether the patient could give informed consent (24%); to determine whether a patient who threatened to leave against medical advice was competent to make 41
Requests for Competency Evaluations
TABLE •• Reason for competency evaluation request by diagnosis
or patient
Diagnosis Delirium or Dementia
One or More Axis. Diagnoses"
Ak:ohol Abuse or Dependence
Axis. Diagnosis Other ThanOMD"
,.
%
,.
%
,.
%
,.
%
Plans to leave against medical advice (n=8)
7
88
2
25
2
25
2
25
Refused diagnostic or treatment procedures (n=8)
6
75
3
38
13
3
38
Need for guardianship (n= 17)
16
94
16
94
7
41
0
0
8
66
7
58
2
18
0
0
I 38
20 76
I
20
29
58
0 12
0 24
0 5
10
Reason for Competency Request
Ability to give informed consent (n=12) OtherC (n=5) Total (n=50)
0
"Many patients had more than one Axis I diagnosis. borganic mental disorder 'This category included questions of mandatory retirement (n= I); fitness to adopt (n= I); possible job impairment (n=2); and competency to compose a will (n= I).
that decision (16%); and to detennine whether a patient was competent to refuse treatment or diagnostic procedures (16%). Other unrelated issues constituted the remaining 10% of requests. One patient was evaluated to detennine the possibility of mandatory retirement; one for fitness to adopt; two for possible impainnent on the job; and one for competency to compose a will. Table I summarizes the types of requests and characteristics of patient groups for which requests to evaluate competency were made. Most requests for competency assessment were considered to be urgent by the requesting physician. More than one-half (58%) were identified as emergencies or were asked to be completed on the same day as the request, as soon as possible, or within 72 hours of the request. Overall, roughly equal proportions of patients were found competent and incompetent (46% and 54%, respectively). However, patients were more likely to be found incompetent and to be psychiatrically committed if they threatened to leave against medical advice. Of eight patients assessed for this reason, only one was found competent (X~.5, df=l, p<.03). Patients who were being evaluated for possible guardianship were also more likely to be found incompetent. Only two of 17 patients in this category were 42
found to be competent (X2=9.94, df=l, p<.OO2). In contrast, patients were largely found to be competent if they refused treatment or diagnostic procedures. Seven of eight patients assessed in this category were found to be competent (X 2=4.5, df=l, p<.03). Patients being evaluated for competency to give infonned consent were largely found to be competent. Only three of 12 patients were found to be incompetent, but the proportion was not significant (X2=3.0, df=l). Seventy-four percent of patients received more than one Axis I diagnosis. Organic mental disorders (OMD) predominated; 58% ofthe sample were diagnosed with delirium or dementia. Twenty-four percent received a diagnosis of alcohol abuse or dependence. Sixty-six percent of patients diagnosed with delirium or dementia were found incompetent (X 2=6.27, df= 1, p<.03). Ninety-four percent of patients whose need for guardianship was evaluated received a diagnosis of delirium, dementia, or both, as did 58% of patients evaluated for their competence to give infonned consent. Of the 12 patients who received a diagnosis of alcohol abuse or dependence, 75% were judged incompetent; eight of these patients had coexisting delirium or dementia. Twenty-five percent of patients threatening to leave AMA and 41 % of patients possibly rePSYCHOSOMATICS
Mebane and Rauch
TABLE 2.
Outcome 01 competency evaluation by diagnosis of patient
DIagnosis
Number of Patients"
Outcome Competent
Incompetent
Organic mental disorders (except alcohol related)
33
II
22
Alcohol-related disorders (abuse or dependence)
12
3
9
Affective disorders depression dysthymia Adjustment disorder depressed mood mixed features
2
Ib
I
0
0
I
2
0
0
I
Axis II disorder
0
I
Schizophrenia
I
0
Diagnosis deferred No diagnosis or V-code diagnosis
I'
13
0
I
13
0
"Many patients had more than one Axis I diagnosis. bActuai diagnosis was borderline personality disorder (adjustment disorder with mixed emotional features and suicide attempt). 'Patient eloped prior to fuIl diagnostic work-up.
quiring guardianship received the diagnosis of alcohol abuse or dependence. Table I summarizes reasons for competency-evaluation request by diagnosis of patients. Overall, non-OMD (functional) Axis I diagnoses were uncommon. Only 10% of patients received diagnoses of functional mental disorders, and all diagnoses were either for major or minor depression (see Table 2). All of the patients with Axis I diagnoses were evaulated for one of two categories-threatening to leave against medical advice (25%) or refusing diagnostic or treatment procedures (38%) (see Table I). No patient received a diagnosis offunctional psychosis; one patient received a secondary diagnosis of schizophrenia, residual type. One patient received an Axis II diagnosis. One patient whose medical work-up was insufficient to differentiate an organic mental disorder from a functional psychosis was judged to be incompetent. Twenty-six percent of all patients had no diagnosis or a DSM-llI V-code diagnosis (life circumstance problem); all of them were judged competent (Table 2). Although the mean age of the sample was 55 years, patients who were assessed to determine if VOLUME 31' NUMBER I • WINTER \990
they required a guardian were significantly older (mean age, 66 years). If we exclude patients evaluated for guardianship, the mean age drops considerably, to 50 years. The average age of the patients referred to determine competence to give informed consent was 48 years; the mean age of patients referred for assessment because they were threatening to leave against medical advice was 52 years; and the mean age of patients referred for assessment because they were refusing diagnostic or treatment procedures was 54 years. The sex ratios, although they were equally distributed over the entire sample, were unevenly distributed in some referral categories. The ratio of men to women who threatened to leave against medical advice was 6:2; the ratio of men to women referred for refusing treatment was 3:5; and the ratio of men to women referred for guardianship was 6: II. Only in the group referred to determine competency to give informed consent was the ratio of males to females equal (6:6). DISCUSSION Strictly speaking, the term competency is of legal rather than psychiatric origin and denotes an 43
Requests for Competency Evaluations
individual's ability to carry on personal business. When used psychiatrically, it refers to an individual's mental capacity to process data and draw conclusions.9 While legal competence is determined by judgment of the courts utilizing statutes and expert testimony (usually from a psychiatrist), psychiatric competence is determined in a bedside setting by the judgment of an experienced clinician utilizing clinical tools like the mental status examination. In both settings. the test of competency varies according to context. The crucial question is not whether an individual is competent in general, but whether he or she is competent to do a particular thing. It is very possible that an individual considered incompetent to conduct financial and legal matters, such as making a will or buying a home, would be found competent to give informed consent for surgery. Drane 10 has suggested that clinicians use a scale that applies increasingly stringent standards of competence as the consequences of the patient's decisions entail more risk to the patient.
While this study was remarkable for demonstrating the extent of psychopathology in the general hospital setting, over-inclusiveness greatly limited the description of both the kinds of patients referred for competency evaluations and the settings in which they are referred. Both the Weinstock et at. II and the Strain et a1.'2 studies alluded to treatment refusal (or refusal to sign a consent form) as a common precipitant to the request for a competency evaluation. Our study shows, however, that even though informed consent might have been the central issue for the consulting psychiatrists, only one-quarter of the referring physicians specifically requested assessment for informed consent. Patients who threatened to leave against medical advice and patients who refused to undergo diagnostic or treatment procedures precipitate nearly one-third of the requests for competency evaluation. Myers and Barrett l3 demonstrated how important refusing treatment and threatening to leave against medical advice are in generating
In genentl. to be considered competent, an indi-
requests for competency evaluation. They retro-
vidual needs only to comprehend the nature ofthe specific conduct in question and to understand its quality and consequences. Two previous attempts to examine the population of patients referred for competency assessment have lumped all requests for competency under the category of informed consent. Weinstock et a1.,'1 on a Veterans Administration psychiatric consultation service, prospectively screened all requests for competence for informed consent. For a request to be realized, a procedure must have been anticipated. Thirty male patients were referred for competency evaluation; three patients were not evaluated because the requests were considered inappropriate (no medical procedure was planned). Ten patients were judged to be incompetent, and all received a diagnosis of an organic brain syndrome. Strain et a1. 12 analyzed legally mandated mental status assessments whereby all patients who seemed not to understand the meaning of consent were referred for psychiatric interviews. Routine requests were made for competency evaluation prior to surgery and procedures.
spectively examined 100 consultation requests and found requests for competency assessment were the initial cause of referral in six cases. Of the six, four patients had threatened to leave against medical advice, and one patient had refused treatment. Only one request was made to determine competency to make informed consent. Myers and Barrett also prospectively examined 100 charts and found nine charts in which questions of competency initiated the consultation request. Five of the nine patients had threatened to leave against medical advice, and four patients had refused treatment. In our study, patients who threatened to leave the hospital against medical advice and patients who refused diagnostic or treatment procedures differed diagnostically and demographically. Patients who threatened to leave against medical advice were usually men, and they were largely found to be incompetent, whereas patients who refused diagnostic or treatment procedures were more commonly women who were largely found to be competent. The finding that
44
PSYCHOSOMATICS
Mebane and Rauch
most patients who refused treatment were competent to do so is consistent with another study that was conducted by Appelbaum and Roth. 14 They found that "the vast majority of those refusing treatment would not be considered mentally ill" (p. 1296). Other investigators ls •16 have commented on the efficacy of physician involvement in reversing the patient's decision to refuse treatment and in mediating when patients threaten to leave against medical advice. However, within these categories, over 33% of patients with Axis I diagnoses displayed eminently treatable psychiatric illness. In addition, the presence of organic mental disorders was lower and seemed to be unrelated to the ultimate decision regarding competency. These are the most dramatic and urgent situations in which psychiatrists are asked to assess competency, and they have an opportunity to make critical and crucial therapeutic interventions. In our study, the consultee and consultant agreed most often when the question of a patient's competence or incompetence involved guardianship. Most patients in this category had experienced long-term, moderate to severe cognitive deterioration that was recognized by family and friends. Many patients had already received a diagnosis of dementia, and involving the courts was considered necessary to long-term care. An unanticipated finding was the high rate of alcohol abuse or dependence among patients referred to determine if guardianships were required. In this and other categories, alcoholism seemed to amplify the possibility that a patient would be judged incompetent. Concordance between consultant and consultee about outcome of competency requests when patients threatened to leave against medical advice was also high. In seven of eight cases, the patients were felt to be dangerous to themselves, and commitment proceedings were initiated to ensure proper psychiatric care. Physicians who requested consultation usually considered this category to be a psychiatric emergency. Low concordance was seen in all other categories. When competence to give informed consent was questioned, many patients had a history VOLUME 31 -NUMBER I-WINTER 1990
of severe and chronic illness, including cerebrovascular accidents. Some patients had received a diagnosis of dementia. The requests for competency evaluation seemed to be generated by a genuine apprehension about the patient's ability to understand. compounded by a lack of family involvement in the decision-making process. When the question of competence involved patients who were refusing diagnostic or treatment procedures, concordance between consultant and consultee was also low. Rather than being generated by a true concern for the patient's ability to participate in decision making, the consultations seemed to be generated by the primary physician's frustration and anger. While patients who refused diagnostic or treatment procedures were not as physically ill as those evaluated for competence to give informed consent, patients who refused diagnostic or treatment procedures had the highest rate of affective disorders. In these cases, consulting physicians felt that the changes in affect (depression, anergy, indecision) were directly responsible for the patient's refusals. For the consulting psychiatrist, the problem of competency arises much more frequently in patients who have previously undiagnosed delirium or dementia 17-in other words, in patients the psychiatrist has been asked to see ostensibly for other reasons. In fact, it is often the consulting psychiatrist who alerts the referring physician to possible informed-consent issues. The conclusion that a particular patient is not competent to participate in informed-consent or treatment decisions is generally not appreciated by the surgeon who has scheduled operating room time or by the cardiologist who is eager to perform coronary angiography. In the clinical arena, this type of dilemma is most often circumvented by consulting with the family and obtaining their permission. However, when the family is not available, the psychiatrist may find himself or herself in a most unenviable position. For this reason, the psychiatrist must be able to furnish informed answers or directions based upon a limited knowledge of the law and of clinical ethics. Unless an awareness of why and when a 45
Requests for Competency Evaluations
physician requests a competency evaluation is balanced with an organized approach to assessment, it is unlikely that the best interests of the patient will be served. Nor is it likely that the psychiatrist will be asked to consult again. The authors thank M. Sackettfor editing and administrative support, MR. Fragala, COL.
USAF, MC (M.D.), M.G. Wise, LTC, USAF, MC (M.D.), and P.P. Roy-Byrne. M.D.Jor editorial assistance and guidance, and the medical editorial department ofAlton Ochsner Medical Foundation. This work was presented at the 40th Institute on Hospital and Community Psychiatry held October 22-27.1988, in New Orleans.
References I. Abernethy V: Compassion, control, and decisions about competency. Am 1 Psychiatry 141 :5~, 1984
Macmillan, 1982 10. Drane IF: Competency to give an informed consent.
2. Sadoff R: Patient rights vs patient needs: who decides? 1 Clin Psychiatry 44:27-32, 1983 3. Sherlock R: Competency to consent to medical care: toward a general view. Gen Hosp Psychiatry 6:71-76, 1984 4. Groves J, Vaccarino J: Legal aspects of consultation, in Hacken T, Cassem N (eds): MassachusetlsGeneral Hospital Handbook of General Hospital Psychiatry. St. Louis, Mosby, 1978. pp 546-561 5. Roth L, Meisel A, Lidz C: Tests ofcompetency to consent to treatment. Aml Psychiatry 134:279-284, 1977 6. Fogel B, Mills M, Landen J: Legal aspects of the treatment of delirium. Hosp Community Psychiatry 37:154-158, 1986 7. Weinstock R, Copelan R, Bagheri A: Physicians' confusion as demonstrated by competency requests. 1 Forensic Sci 30:37-43,1985 8. American Psychiatric Association: Diagnostic andStatistical Manual ofMental Disorders. Third Ed. Washington, DC, American Psychiatric Association, 1980 9. Jonsen AR, Siegler M (eds): Clinical Ethics. New York,
lAMA 252:925-927,1984 II. Weinstock R. Copelan R. Bagheri A: Competence to give informed consent for medical procedures. Bull Am Acad Psychiatry Law 12:117-125. 1984
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12. Strain J, Taintor Z, Gise L, et aI: Informed consent-mandating the consultation. Gen Hosp Psychiatry 7:228-233, 1985 13. Myers B. Barren C: Competency issues in referrals to a consultation-liaison service. Psychosomatics 27:782789, 1986 14. Appelbaum P, Roth L: Patients who refuse treatment in medical hospitals. lAMA 250:1296-1301,1983 15. Albert H, Kornfeld D: The threat to sign out against medical advice. Ann Intern Med79:888-89I, 1973 16. Himmelhock J, Davis N, Tucker G, et aI: Buning heads: patients who refuse necessary procedures. Psychiatry Medl:241-249,1970 17. Folks D, Ford C: Psychiatric disorders in geriatric medicaVsurgical patients: part I. Report of 195 consecutive consultations. South Med 1 78:239-241, 1985
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