Better Call Saul: Chuck's EM allergy

[whopper]

If you don't watch the show and might don't read on. It has spoilers and the show is good.

Chuck McGill suffers from a delusional with strong psychosomatic sx that he's allergic to EM fields. This condition does exist though the amount of people who have it is so rare it's not taught in conventional psychiatric training. People since the emergence of wifi claimed it caused them to have problems such as headaches, memory lapses, nausea, etc. Turned out when these people were placed in magnetically shielded rooms and told to be able to tell if an electronic device was off or on (by being asked if they had side effects) there was no correlation with the device. Further in other cases where people c/o of say a cell phone tower giving them health problems, it turned out the cell-phone tower was not operational for months.

Due to Chuck's delusion he confines himself to his home, keeps everything shut off, and wears a blanket of aluminum thermal wrap believing it protects him from EM waves.

In the last few episodes of season 3 Chuck suffers a psychosomatic syncopal episode and falls and hits his head. He's brought to the hospital and refuses any interventions involving electricity such as a CT scan, an EKG, being hooked up to a vital signs machine but because he seems so delusional the hospital staff ignore him and do it anyway.

So the big question. Did Chuck have capacity to refuse? He's brilliant, in full command of his cognition, memory, he's a highly educated, Ivy-League trained lawyer who has argued cases in front of the highest courts in the country and he's refusing intervention based on a delusional belief that he has an EM wave allergy. (So seems like he doesn't have capacity)

But that delusional belief causes him to have real psychosomatic sx that are so bad he could go into panic attacks, syncope, even catatonia in 2 occasions where he was placed in a state of high anxiety for extended durations. Despite that the psychosomatic problems are based on delusion the psychosomatic sx are real. (So does that mean he has capacity?)

---

Members don't see this ad.

 

[nexus73]

I think in this specific situation he does not have capacity to decline emergent medical workup. Because essentially something could be going on which could end up killing him (brain bleed, life threatening arrhythmia), and ruling that in or out may be crucial for him to go on living. Whereas if he is forced to undergo the procedures, he faces perhaps some very negative effects such as panic attacks or catatonia, neither of which is likely to kill him. He won't be able to demonstrate the appreciation of the TRUE risk...he'll say that "Sure I might die from an arrhythmia, but if you put me in a CT scanner I'm sure to die because I'm allergic to EM waves." He won't be objecting to the procedure out of concern it will cause potential panic attacks or catatonia. That being said, you'd have a hell of a time getting someone like this into a CT scanner without high dose tranquilizers.

From an art of medicine standpoint, if the risk of finding something potentially fatal is low enough, you'd probably just do the best history and physical exam possible and not force the issue. Tranquilizing someone to get a CT done is extremely invasive, and you'd essentially be destroying any rapport you have with this patient should they have problems in the future.

 

[OldPsychDoc]

Well the cure for catatonia is...

Wait for it...

😀

ECT.

 

[whopper]

My wife and I just saw the episode a few days ago and it was an ethics/legal goldmine and the medical presentation was highly accurate. The ER staff did the same exact tests they were supposed to do and the technical data was presented accurately including the droning ER responses that seemed like they didn't care when Chuck is crying and begging them not to do tests.

My wife said the same thing and she is a mental health professional. What if they gave him ECT!?!?!

 

[nitemagi]

One can argue he can't appreciate the risks/benefits/alternatives of getting the scans since he has a false belief about how they will hurt him, and therefore doesn't have capacity.

I might try to get him to buy into the belief that an MRI will "flip" the electrons in him and render him immune to all further EM effects. Maximize the placebo. 😀

 

[WisNeuro]

I might try to get him to buy into the belief that an MRI will "flip" the electrons in him and render him immune to all further EM effects. Maximize the placebo. 😀

Well, MRI scan rooms are Faraday cages, so you could just turn out the lights and tell him that the room filters out outside electronic interference and still be telling the full truth.

 

[OldPsychDoc]

One can argue he can't appreciate the risks/benefits/alternatives of getting the scans since he has a false belief about how they will hurt him, and therefore doesn't have capacity.

I might try to get him to buy into the belief that an MRI will "flip" the electrons in him and render him immune to all further EM effects. Maximize the placebo. 😀

Like lighting a backfire.

 

[whopper]

IMHO....
He lacks capacity to refuse tests for potentially life-threatening situations.

But he has the capacity to refuse routine tests if he can acknowledge that his problem "could be" psychosomatic but that psychosomatic problems cause him to suffer and therefore should be acknowledged as real.

The law has established that informed consent is on a graduated/sliding-scale level. Guy is unconscious and needs treatment or will die? You don't need their verbal consent. If a guy needs a routine test and it's not life threatening you're supposed to get their consent.

The big area of debate comes with everything in-between. E.g. what if he didn't get out of the catatonia for a few days but there's no detectable rhabdomyolysis? What then?

 

[PsyDr]

I might try to get him to buy into the belief that an MRI will "flip" the electrons in him and render him immune to all further EM effects. Maximize the placebo. 😀

I have done something extremely similar to this, with positive results.

 

[Salpingo]

IMHO....
He lacks capacity to refuse tests for potentially life-threatening situations.

But he has the capacity to refuse routine tests if he can acknowledge that his problem "could be" psychosomatic but that psychosomatic problems cause him to suffer and therefore should be acknowledged as real.

The law has established that informed consent is on a graduated/sliding-scale level. Guy is unconscious and needs treatment or will die? You don't need their verbal consent. If a guy needs a routine test and it's not life threatening you're supposed to get their consent.

The big area of debate comes with everything in-between. E.g. what if he didn't get out of the catatonia for a few days but there's no detectable rhabdomyolysis? What then?

Why does he have to acknowledge the problem could be psychosomatic?

If he's able to recognize the risks and benefits of receiving (or not receiving) the tests, can express understanding of the medical conditions the teams are testing for, and can give a consistent, rational line of thinking ("I know I may have an intracranial bleed, but the distress of receiving these medical tests now and in the near future are so great that I am willing to accept the risk of having it go undiagnosed"), isn't that sufficient? If a patient refused an MRI because they were claustrophobic, wouldn't they have capacity to do so? Or refuse chemotherapy if it would be too emotionally/physically taxing? Again, all assuming the patient understand and appreciates the risk they're taking on in order to avoid discomfort and suffering.

My sense is that he lacks capacity because he can't articulate his thinking beyond "NO CT SCAN!" and "I have a condition... I don't give you my consent!... You're killing me!"

That being said, the scene is really brilliantly shot, with the camera trained on his restrained head while faceless gloved hands come in and out. Really gives you an appreciation for all the probing and invasiveness that comes with being a patient, the degree of suffering we put our patients through without even thinking about the consequences of our actions/words, all because we're in our own little world (e.g. when they shove the otoscope in his ear, "he's on a 5-lead now... we're going to need a 12-lead"

 

[WisNeuro]

Why does he have to acknowledge the problem could be psychosomatic?

If he's able to recognize the risks and benefits of receiving (or not receiving) the tests, can express understanding of the medical conditions the teams are testing for, and can give a consistent, rational line of thinking ("I know I may have an intracranial bleed, but the distress of receiving these medical tests now and in the near future are so great that I am willing to accept the risk of having it go undiagnosed"), isn't that sufficient? If a patient refused an MRI because they were claustrophobic, wouldn't they have capacity to do so? Or refuse chemotherapy if it would be too emotionally/physically taxing? Again, all assuming the patient understand and appreciates the risk they're taking on in order to avoid discomfort and suffering.

That is indeed sufficient from a legal point of view, as long as they can restate the risks of not receiving the care, after the risks and potential benefits have been clearly explained to them. That last is usually the kicker. Usually when I have been called in for a capacity consult, no one has done that last part with the patient.

 

[whopper]

Why does he have to acknowledge the problem could be psychosomatic?

If he's able to recognize the risks and benefits of receiving (or not receiving) the tests, can express understanding of the medical conditions the teams are testing for, and can give a consistent, rational line of thinking ("I know I may have an intracranial bleed, but the distress of receiving these medical tests now and in the near future are so great that I am willing to accept the risk of having it go undiagnosed"), isn't that sufficient? If a patient refused an MRI because they were claustrophobic, wouldn't they have capacity to do so? Or refuse chemotherapy if it would be too emotionally/physically taxing? Again, all assuming the patient understand and appreciates the risk they're taking on in order to avoid discomfort and suffering.

An extremely great argument that demonstrates you know what you're talking about!

You could be right!

My counter-argument would be that in-the-moment, when one's distress is that great-from a psychosomatic and delusional illness the general understanding has been that this could also strongly suggest the patient doesn't understand. After all the arguments could also be used for a schizophrenia who believes the treatment staff are government agents who are giving the medication to control him. Would the staff members injecting him against his will cause his distress? Also despite that you gave a very strong argument it's predicated on his delusional belief that a judge could find as fitting the description of not having capacity/competency.

It is your very argument as to why I find that specific scenario possibly still up in the air in terms of whether or not a judge would've ruled Chuck as having competency or not and why I brought it up. I mentioned my opinion but I can see some judges going against it. Further I've never seen a case like this ever in my life, and I'm not simply talking about the delusional EM allergy. I'm talking about a person not wanting treatment due to a delusion for a potentially life-threatening situation where the delusion is so complicit with treatment. E.g. EKG or a CT scan and he thinks he's allergic to the treatment but also will suffer so terribly from it.

When the idea of a graduated competency scale was introduced into case-law it never ventured into the several gradations. While we so those daily in consult psych, never has the court sat through and gave codified examples of all the in-between scenarios (nor does a legal expert likely want to go through such, but having this lack of case examples where the law touched upon it and gave a clear judgment gives lack of direction and foundation for clinicians when weird cases happen.

 

[Salpingo]

An extremely great argument that demonstrates you know what you're talking about!

You could be right!

My counter-argument would be that in-the-moment, when one's distress is that great-from a psychosomatic and delusional illness the general understanding has been that this could also strongly suggest the patient doesn't understand. After all the arguments could also be used for a schizophrenia who believes the treatment staff are government agents who are giving the medication to control him. Would the staff members injecting him against his will cause his distress? Also despite that you gave a very strong argument it's predicated on his delusional belief that a judge could find as fitting the description of not having capacity/competency.

It is your very argument as to why I find that specific scenario possibly still up in the air in terms of whether or not a judge would've ruled Chuck as having competency or not and why I brought it up. I mentioned my opinion but I can see some judges going against it. Further I've never seen a case like this ever in my life, and I'm not simply talking about the delusional EM allergy. I'm talking about a person not wanting treatment due to a delusion for a potentially life-threatening situation where the delusion is so complicit with treatment. E.g. EKG or a CT scan and he thinks he's allergic to the treatment but also will suffer so terribly from it.

When the idea of a graduated competency scale was introduced into case-law it never ventured into the several gradations. While we so those daily in consult psych, never has the court sat through and gave codified examples of all the in-between scenarios (nor does a legal expert likely want to go through such, but having this lack of case examples where the law touched upon it and gave a clear judgment gives lack of direction and foundation for clinicians when weird cases happen.

I see your point with the treatment of schizophrenia, although I think that's a separate issue - in that case, the patient is being treated FOR schizophrenia (which is presumably causing direct harm or incapacitating them). A person with schizophrenia can still demonstrate capacity to refuse a test or procedure, although more challenging.

This has been partially been put to the test, with a woman in the NJ state hospital system was released and allowed to seek palliative care for anorexia nervosa, on grounds that treatment of malnourishment was too distressing (although there were also elements of "right to die" and the fact that she had already "failed" multiple prior treatment attempts for 10+ years with significant medical consequences). Like the Chuck case, the delusion (in this case of being fat and worthless) is directly at odds with medical care for treating malnourishment.

The biggest hurdle I'd imagine a person with delusional disorder would have making my argument is yielding the fact that the medical tests themselves may or may not have a permanent physical effect on them, and focusing instead on the emotional distress. My experience with delusional disorder patients is that they're almost compelled to prosthelytize and convince others there's a CONCRETE reality to their belief system, as opposed to shrugging their shoulders, saying "agree to disagree" on the physical symptoms, but that "we can all agree my emotional distress is real."

 

[Salpingo]

That is indeed sufficient from a legal point of view, as long as they can restate the risks of not receiving the care, after the risks and potential benefits have been clearly explained to them. That last is usually the kicker. Usually when I have been called in for a capacity consult, no one has done that last part with the patient.

Yeah, I think whats interesting about this case is that the people administering these tests have no idea that there ARE inherent risks -- imagine consenting a patient to have an otoscope inserted or exam light turned on or ECG strips applied. Yet for a reasonable chunk of our patients (I'm thinking severe OCD, autism, somatic delusions) there's a traumatic component to these actions that most doctors wouldn't think twice about or even dream of requiring consent (although this may be more like the consent required of a pelvic exam, for example, as opposed to capacity consent).