Capacity consult, chronic delusions, refusing pacemaker

[nexus73]

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Patient in their 60s with schizophrenia, meds optimized on Invega Sustenna, stable at ALF for years. Has chronic delusions of being monitored, doesn't trust machines. Then he started passing out, admitted to the hospital, found to have frequent runs of asystole and cardiology recommends pacemaker. He doesn't want it (it's a machine, of course). He lacks decisional capacity. High likelihood of death without it.

What do you think should happen with someone like this. Other than refusing care he is alert and oriented, super pleasant. Family is available as proxy to consent to pacemaker placement. Should this patient be tranquilized and have the pacemaker implanted?

This really gets at the question of what to do with the lucid patient who needs urgent invasive treatment and lacks capacity. Are doctors tranquilizing patients in their hospital beds, only for them to awaken with a new piece of medical hardware installed? Or osteomyelitic foot amputated? etc etc

 

[Fan_of_Meehl]

Patient in their 60s with schizophrenia, meds optimized on Invega Sustenna, stable at ALF for years. Has chronic delusions of being monitored, doesn't trust machines. Then he started passing out, admitted to the hospital, found to have frequent runs of asystole and cardiology recommends pacemaker. He doesn't want it (it's a machine, of course). He lacks decisional capacity. High likelihood of death without it.

What do you think should happen with someone like this. Other than refusing care he is alert and oriented, super pleasant. Family is available as proxy to consent to pacemaker placement. Should this patient be tranquilized and have the pacemaker implanted?

This really gets at the question of what to do with the lucid patient who needs urgent invasive treatment and lacks capacity. Are doctors tranquilizing patients in their hospital beds, only for them to awaken with a new piece of medical hardware installed? Or osteomyelitic foot amputated? etc etc

Interesting case. I'd like to know a bit more (specifics) about his chronic delusions of 'being monitored' and not trusting machines. Have these beliefs been associated by past decision-making of this patient in any way that was harmful to him or others? Just how extreme/bizarre are they? Are they embedded in any general philosophical / moral framework? Is his thinking strongly illogical outside of his specific beliefs regarding machines or technology? Do these beliefs wax/wane along with specifiable episodes of worsened psychopathology (e.g., manic or depressive episodes, periods of heightened psychotic symptoms) or in response to medication adjustments? Does he express knowledge that he will likely die without the pacemaker? What does he say about that possibility? What has he said about his beliefs regarding what would happen if he did have the pacemaker implanted? Does he think that it will take over his body and mind and cause him to do things he doesn't want to do or does he just object to the implantation of mechanical devices into his body on principle, or something? Are there alternative treatment options (medications, surgery that doesn't involve implantation of machines) that have been described to him along with relative probabilities of success/failure of the interventions compared to the implanted pacemaker? What does he think about pacemakers, in particular?

Hopefully you have access to a hospital ethics committee and/or trusted colleagues to weigh in on this case.

 

[nexus73]

He has schizophrenia, no history of mood component. He's not delirious/demented. Family says delusions about being monitored and "machines" in particular have been persistent for years. The delusions aren't rooted in an ideology. When he was off meds previously family said he was much worse, frequent hospitalizations, etc. Last several years, 5+ on sustenna have been most stable ever. Functioning fine day to day at ALF, but delusions have not remitted. Worries that machines will monitor his location and if in his body could kill him. It is hard to have a nuanced discussion about the what ifs with the pacemaker, like what does he worry about specifically, as he gets dysregulated and reverts back to how he just will not have it done.

He does not demonstrate understanding of the lethal nature of his heart condition. Actually, in discussing it, he borders dangerously close to attributing the heart condition to his antipsychotic and wanting to stop it to prove to everyone that it's from his meds. He does not think the heart problem could kill him despite education from physicians, believes physicians are lying to him in effort to implant a machine.

Cards says there are no other treatment options, it's pacemaker or cross fingers and hope his heart doesn't stop completely.

Ethics is on the case.

 

[wolfvgang22]

Keep us updated.

 

[psyduck1990]

How likely is this guy to dig out the pacemaker with a knife if you force it on him? He lacks capacity but just thinking practically here.

 

[Bartelby]

I recommend:

1- discuss with legal. Find out if there is any legal way to force the intervention. If no, your job is done! Have outpatient treaters continue working on delusional content in hopes he comes to assent to treatment.

2- If you do have a legal pathway to intervene, weigh the situation carefully with the ethics committee and primary team. Often surgical teams will refuse to put someone under and perform a procedure when that person will fight every step of the way. Make sure everyone is documenting the tremendous thoughtfulness and interdisciplinary collaboration used to reach that decision, because of course you expect a bad outcome.

3- if intervening is legal and the team chooses to pursue it, be ready for prompt management of agitation and potential worsening of psychosis.

These cases are very difficult and emotionally charged, in my experience in large part because typically the law does not clearly spell out what to do and you could be on the hook with with either route. You want a lawyer involved and weighing in at minimum.

 

[forchinet121]

I recommend:

1- discuss with legal. Find out if there is any legal way to force the intervention. If no, your job is done! Have outpatient treaters continue working on delusional content in hopes he comes to assent to treatment.

2- If you do have a legal pathway to intervene, weigh the situation carefully with the ethics committee and primary team. Often surgical teams will refuse to put someone under and perform a procedure when that person will fight every step of the way. Make sure everyone is documenting the tremendous thoughtfulness and interdisciplinary collaboration used to reach that decision, because of course you expect a bad outcome.

3- if intervening is legal and the team chooses to pursue it, be ready for prompt management of agitation and potential worsening of psychosis.

These cases are very difficult and emotionally charged, in my experience in large part because typically the law does not clearly spell out what to do and you could be on the hook with with either route. You want a lawyer involved and weighing in at minimum.

On the hook for what? Patient does not have capacity so his family makes the decision, it doesn’t seem like a complicated case

 

[Bartelby]

On the hook for what? Patient does not have capacity so his family makes the decision, it doesn’t seem like a complicated case

You could be potentially on the hook for:

1- a wrongful death claim. The family as non-court-appointed surrogate decision makers typically cannot authorize care over objection. If, however, you failed to utilize a pathway to legally authorize care then the family might bring a claim that this fell below the relevant standard of care. This is especially true if the family disagrees among themselves about the right course of care.

2- battery or malpractice if you sedate and operate on a patient over their objections and it turns out that you did not have legal grounds to do so. For instance, the family likely cannot authorize care over the patient's active objection. If you go forward anyway, there may be grounds for a criminal or civil claim.

Fortunately neither of the above are likely, but this is a high-stakes decision legally and you want good guidance about local law and case precedent. Keep in mind that this care is life-saving, but the patient is conscious and vigorously refusing the procedure. That changes things v a patient who is, say, unconscious or who lacks capacity but will offer assent.

 

[WisNeuro]

On the hook for what? Patient does not have capacity so his family makes the decision, it doesn’t seem like a complicated case

Depends on the documentation and CYA that the clinician does. You can take the same case, with different documentation, and get very different results in a legal setting.

 

[forchinet121]

Depends on the documentation and CYA that the clinician does. You can take the same case, with different documentation, and get very different results in a legal setting.

Can you elaborate? What’s the worst that could happen?

 

[forchinet121]

You could be potentially on the hook for:

1- a wrongful death claim. The family as non-court-appointed surrogate decision makers typically cannot authorize care over objection. If, however, you failed to utilize a pathway to legally authorize care then the family might bring a claim that this fell below the relevant standard of care. This is especially true if the family disagrees among themselves about the right course of care.

2- battery or malpractice if you sedate and operate on a patient over their objections and it turns out that you did not have legal grounds to do so. For instance, the family likely cannot authorize care over the patient's active objection. If you go forward anyway, there may be grounds for a criminal or civil claim.

Fortunately neither of the above are likely, but this is a high-stakes decision legally and you want good guidance about local law and case precedent. Keep in mind that this care is life-saving, but the patient is conscious and vigorously refusing the procedure. That changes things v a patient who is, say, unconscious or who lacks capacity but will offer assent.

I’m not sedating anyone, I’m stating the patient does not have capacity in my opinion, that’s pretty much all I’m going to say, when a patient doesn’t have capacity his kin make the decision, what the surgeon chooses to do with that info is up to them, and they should also consult the ethics committee, I’m only giving an opinion on capacity nothing else

 

[nexus73]

How likely is this guy to dig out the pacemaker with a knife if you force it on him? He lacks capacity but just thinking practically here.

That is a concern. Apparently, they make a leadless pacemaker that is implanted via femoral artery and gets implanted into the ventricle wall. So no skin cavity or big device bump on the upper chest. Though cutting out a pacer implanted into the ventricle isn't off the table I suppose.

 

[Bartelby]

I’m not sedating anyone, I’m stating the patient does not have capacity in my opinion, that’s pretty much all I’m going to say, when a patient doesn’t have capacity his kin make the decision, what the surgeon chooses to do with that info is up to them, and they should also consult the ethics committee, I’m only giving an opinion on capacity nothing else

If you can limit it to that, then your liability risk seems very low. It also becomes a very straightforward consult.

Where I have done consults, the psychiatric team would help guide next steps for people who lack capacity. We see a lot of these situations compared to most other physicians, so that becomes very helpful to the primary team. If the culture has been set to simply say "lacks capacity" and then sign off, though, that sounds pretty sweet 😀.

 

[nexus73]

If this patient demanded to leave, would you place him on a mental health hold, to force him to stay, and cardiology can do the procedure if they choose to do so? There are no medical holds here.

 

[WisNeuro]

Can you elaborate? What’s the worst that could happen?

As Bartelby stated above, if documentation is not done properly, you are on the hook for any negative outcome, regardless of whether or not teh family is on board. Liability is low as long as you have the capacity evaluation properly documented, along with any consults (e.g., hospital ethics board) completed. Mostly just a CYA thing. Unfortunately poor documentation of capacity was the norm rather than the exception, in my experience.

 

[Geraltofrivia]

IMO patient doesn't have capacity. Substituted judgment comes from family. Surgeon or cardiology won't operate because they have to sedate and intubate patient probably. This should go to legal and probably court for a legal order to treat over objection. But going to court will hinge in your evaluation so you may have to testify.

That's what I think though

 

[SmallBird]

As Bartelby stated above, if documentation is not done properly, you are on the hook for any negative outcome, regardless of whether or not teh family is on board. Liability is low as long as you have the capacity evaluation properly documented, along with any consults (e.g., hospital ethics board) completed. Mostly just a CYA thing. Unfortunately poor documentation of capacity was the norm rather than the exception, in my experience.

With respect that is nonsense! Even involuntary treatment has risks, benefits and alternatives and saying someone does not have capacity does not transfer the responsibility for any negative outcome to the psychiatrist. That is why a capacity evaluation should way the likelihood of the treatment being successful. Documentation is important yes but poor documentation doesn't transfer this liability.

 

[WisNeuro]

With respect that is nonsense! Even involuntary treatment has risks, benefits and alternatives and saying someone does not have capacity does not transfer the responsibility for any negative outcome to the psychiatrist. That is why a capacity evaluation should way the likelihood of the treatment being successful. Documentation is important yes but poor documentation doesn't transfer this liability.

If you are the one performing the capacity evaluation, you are taking on some of that liability. Whether or not you believe that is nonsense or not matters little to the courts. Documentation is your safeguard to lowering that liability as much as you can.

 

[shoomer]

That is a concern. Apparently, they make a leadless pacemaker that is implanted via femoral artery and gets implanted into the ventricle wall. So no skin cavity or big device bump on the upper chest. Though cutting out a pacer implanted into the ventricle isn't off the table I suppose.

You would still have to notify the patient that they have this pacemaker though right? In order to make sure they're safe for machines like MRIs, have follow-up with cardiology, etc.

 

[SmallBird]

If you are the one performing the capacity evaluation, you are taking on some of that liability. Whether or not you believe that is nonsense or not matters little to the courts. Documentation is your safeguard to lowering that liability as much as you can.

Help me understand - if the cardiologist tries to consent the patient, they decline, you do a capacity evaluation to the standard of a reasonable physician, and they perform the procedure to the standard of a reasonable physician, but the procedure has a negative outcome, then you as the psychiatrist have some liability? That doesn't make sense. Is there any evidence of that ever happening? Do you have a case?

 

[adiradirim]

How likely is this guy to dig out the pacemaker with a knife if you force it on him? He lacks capacity but just thinking practically here.

Exactly, there's a healing process after the implant. The implant is usually right under the skin on the front of the chest, very easily accessible. If he tries to dig it out immediately after, would he be put in restraints for weeks while it is healing? What if he digs it out later, would it be replaced? The batteries run out over time and need replacement in the future, how would you handle that? I'm assuming there would be follow up care for it as well to consider.

I think in this case he lacks capacity, but he also fails the psychological evaluation to have an implanted device and is a very high risk candidate.
It would be up to the cardiology team to decide if the medical benefit outweighs the risks.

Very interesting case, good luck!

 

[WisNeuro]

Help me understand - if the cardiologist tries to consent the patient, they decline, you do a capacity evaluation to the standard of a reasonable physician, and they perform the procedure to the standard of a reasonable physician, but the procedure has a negative outcome, then you as the psychiatrist have some liability? That doesn't make sense. Is there any evidence of that ever happening? Do you have a case?

Liability is never 0 when you are involved in the care. IF you do the capacity evaluation to a reasonable standard and document appropriately, you can reduce that liability quite a bit, and your chances of any adverse action are pretty low. If you do capacity consults, may be worth a consult with your liability carrier in some circumstances, which you can further document.

 

[PsyDr]

A. Wait, you're leaving out the biggest issue here. HOW is this person in an ALF?
1. It seems unlikely that a delusional person, who is adverse to being monitored, is voluntarily living in an environment that requires monitoring. How did they get into the facility? Did they do it 100% voluntarily? Or did the family get POA/Guardianship and get them into the facility?
2. How did the family get the right to make healthcare decisions? Do they have POA? Guardianship? This really seems like they have one of those.
3. After you define #2, look up your state's laws about power of attorney and/or guardianship. There is usually a word document on your state's website. Download it. See if the incapacitated person can enter into contracts, such as hiring an attorney. Usually they cannot. Ask the family for that document.
4. If the person cannot hire an attorney, you have almost no liability.

B. Approaches.
1. One could argue that a pacemaker interrupts the cell phone, radio, and wifi signals. If one believed that, and were adverse to those signals, a pacemaker might suddenly become desirable.
2. You can always see if the device salesman will meet with the patient. They take all sorts of stupid calls.
3. Incapacitated people receive invasive treatments all the time, including amputations and implantations. Ever woken up from surgery with a catheter?

 

[Bartelby]

Help me understand - if the cardiologist tries to consent the patient, they decline, you do a capacity evaluation to the standard of a reasonable physician, and they perform the procedure to the standard of a reasonable physician, but the procedure has a negative outcome, then you as the psychiatrist have some liability? That doesn't make sense. Is there any evidence of that ever happening? Do you have a case?

A good case example re: needing good documentation would be Shine v Vega (SHINE vs. VEGA, 429 Mass. 456). Basically, a woman came into the MGH ER having a life-threatening asthma attack. They recommended intubation. She refused, and ended up trying to elope. The team intubated her over her objections. Per her family, she developed PTSD-like symptoms as a result and refused to go to a hospital for future attacks. She later died at home during another severe asthma attack. Her family brought suit against the physicians who intubated her against her will. The physicians won at trial, but on appeal it was determined that the jury instructions were inappropriate and that the jury must consider whether Shine had the capacity to refuse the intervention (even though it was a life-threatening emergency). If I recall correctly, a lack of documentation on this point was key to increasing the odds of a favorable plaintiff's verdict. I believe the case ultimately settled, but I could be wrong (it's been a while since I reviewed this stuff).

In your example, let's say you do the capacity evaluation and inform the team that the patient lacks capacity and they should obtain consent from the family for the life-saving care. In your state, though, what if the proper pathway is to obtain an administrative hearing to authorize care over the patient's objections? In that case, you advised proceeding without proper legal consent. It could be alleged that you performed below the relevant standard for a psychiatrist in your area.

Or, let's say that you don't document or document minimally. The family (several of whom adamantly oppose the operation, though the key decision makers support it) record the patient lucidly stating exactly what the operation is, that he does not want it, and then screaming and fighting as the team wheels him back. The patient subsequently worsens significantly, or has an adverse outcome related to the procedure. The family brings suit claiming that the team proceeded without informed consent and that he was competent. You want firm documentation that would be convincing to a lay person showing why this person, who was conscious, understood exactly what the procedure was, and was yelling not to do it was unable to make that decision for himself.

In these hypothetical examples, you would likely have a good chance of winning at trial, but an attorney might bring a claim hoping for a settlement (which is how most civil litigation ends). The better the documentation, the better the chance an attorney decides it isn't worth it to even try bringing a claim. If your documentation is minimal and the Plaintiff's team has footage of the patient speaking seemingly lucidly about how much he does not want the procedure and then fighting the team who does it anyway, I think a settlement (or, less likely, a win at trial) could be possible.

 

[nexus73]

A. Wait, you're leaving out the biggest issue here. HOW is this person in an ALF?
1. It seems unlikely that a delusional person, who is adverse to being monitored, is voluntarily living in an environment that requires monitoring. How did they get into the facility? Did they do it 100% voluntarily? Or did the family get POA/Guardianship and get them into the facility?
2. How did the family get the right to make healthcare decisions? Do they have POA? Guardianship? This really seems like they have one of those.
3. After you define #2, look up your state's laws about power of attorney and/or guardianship. There is usually a word document on your state's website. Download it. See if the incapacitated person can enter into contracts, such as hiring an attorney. Usually they cannot. Ask the family for that document.
4. If the person cannot hire an attorney, you have almost no liability.

B. Approaches.
1. One could argue that a pacemaker interrupts the cell phone, radio, and wifi signals. If one believed that, and were adverse to those signals, a pacemaker might suddenly become desirable.
2. You can always see if the device salesman will meet with the patient. They take all sorts of stupid calls.
3. Incapacitated people receive invasive treatments all the time, including amputations and implantations. Ever woken up from surgery with a catheter?

Great questions and ideas.

This guy really likes the ALF, doesn't seem like chronic delusions have interfered with him being a resident there for several years. People with schizophrenia live in ALFs around here without POAs or guardians to sign them in.

Family doesn't have a legal document to make healthcare decisions. State law outlines the algorithm for proxy decision makers if the patient lacks capacity. It's spouse, parents, adult children, siblings...something like that. But we have the correct proxy identified per statute. The primary team may be asking him to sign a POA for a family member now, but I'm not sure how that would hold legally. The patient doesn't want a procedure, but willingly consent to abdicate their decision-making authority to someone who will authorize the procedure essentially as soon as the document is signed. I'm guessing he might not fully understand what he's agreeing to.

I'd love to get the pacemaker rep into the hospital on a weekend. Just imagining some good looking 30 something dude. "Sir, let me tell you, this is the best pacemaker on the market, it's got everything!"

 

[TheRightMedication]

Psyduck is right to ask about how likely he is to harm himself if you put the device in. If he's said anything about cutting it out, that's strong evidence of an adverse outcome and that could be the end of the discussion.

I'm curious how acute the situation is: can he be hospitalized to try adjunctive clozaril, assuming he'd take it? I appreciate that the case is described as stable with residual delusions, but just a thought.

 

[nexus73]

Psyduck is right to ask about how likely he is to harm himself if you put the device in. If he's said anything about cutting it out, that's strong evidence of an adverse outcome and that could be the end of the discussion.

I'm curious how acute the situation is: can he be hospitalized to try adjunctive clozaril, assuming he'd take it? I appreciate that the case is described as stable with residual delusions, but just a thought.

Another good thought. I think the art of medicine ends up coming into play here convincing someone who wants to go home they should actually stay in the hospital with transcutaneous pacers in place, to start a new antipsychotic medicine for some reason. But I think it's a great idea, he's never been on clozapine. The ALF actually may not be taking him back until something gets done so that could be some leverage as well, I suppose.

 

[nexus73]

Also, just so everyone knows (free medicine CME for the day) there is one approved "leadless" pacemaker. No wires, no chest bump, so not noticeable externally.

Is a Leadless Pacemaker Right for You?

Learn more about the pros and cons of leadless pacemakers.

my.clevelandclinic.org

Micra - Pacemakers

Find helpful patient information about Medtronic leadless Micra pacemakers for the treatment of bradycardia (slow heartbeat) and MRI safety.

www.medtronic.com

 

[G Sheb]

A good case example re: needing good documentation would be Shine v Vega (SHINE vs. VEGA, 429 Mass. 456). Basically, a woman came into the MGH ER having a life-threatening asthma attack. They recommended intubation. She refused, and ended up trying to elope. The team intubated her over her objections. Per her family, she developed PTSD-like symptoms as a result and refused to go to a hospital for future attacks. She later died at home during another severe asthma attack. Her family brought suit against the physicians who intubated her against her will. The physicians won at trial, but on appeal it was determined that the jury instructions were inappropriate and that the jury must consider whether Shine had the capacity to refuse the intervention (even though it was a life-threatening emergency). If I recall correctly, a lack of documentation on this point was key to increasing the odds of a favorable plaintiff's verdict. I believe the case ultimately settled, but I could be wrong (it's been a while since I reviewed this stuff).

In your example, let's say you do the capacity evaluation and inform the team that the patient lacks capacity and they should obtain consent from the family for the life-saving care. In your state, though, what if the proper pathway is to obtain an administrative hearing to authorize care over the patient's objections? In that case, you advised proceeding without proper legal consent. It could be alleged that you performed below the relevant standard for a psychiatrist in your area.

Or, let's say that you don't document or document minimally. The family (several of whom adamantly oppose the operation, though the key decision makers support it) record the patient lucidly stating exactly what the operation is, that he does not want it, and then screaming and fighting as the team wheels him back. The patient subsequently worsens significantly, or has an adverse outcome related to the procedure. The family brings suit claiming that the team proceeded without informed consent and that he was competent. You want firm documentation that would be convincing to a lay person showing why this person, who was conscious, understood exactly what the procedure was, and was yelling not to do it was unable to make that decision for himself.

In these hypothetical examples, you would likely have a good chance of winning at trial, but an attorney might bring a claim hoping for a settlement (which is how most civil litigation ends). The better the documentation, the better the chance an attorney decides it isn't worth it to even try bringing a claim. If your documentation is minimal and the Plaintiff's team has footage of the patient speaking seemingly lucidly about how much he does not want the procedure and then fighting the team who does it anyway, I think a settlement (or, less likely, a win at trial) could be possible.

I do not think it is your job to provide guidance what to do next.
You can, but why would you put yourself in that minefield? Point is, that is not what is expected from the consult (and do not think that is the standard of care). The obvious answer would be to consult hospital administration and ethics committee for legal and ethical advice.

If you get a consult for capacity, your job is to assist in determining capacity.
Now yes, if you do a crappy job documenting your capacity evaluation then I can't see any reason why you wouldn't be held liable in case the family sues.

 

[Candidate2017]

It seems to me he lacks decision making capacity as to pacemaker treatment, which then punts the decision to his family/guardian/surrogate.

In my opinion, if I were his surrogate, I'd decline pacemaker treatment and try less invasive options with the understanding he will likely eventually decompensate and die. As you say, this is a long term, elderly schizophrenic optimized on Invega, who is chronically suspicious of machines. No amount of psychotropics, involuntary psych hospitalization, or less invasive pacemaker can change this and will only cause him more harm and trauma.

There is too much hand wringing in psychiatry, I feel, in regard to patients dying (and resulting liability) despite our best practices. We are not obligated to keep people alive indefinitely, and we do not have the ability to do so. Schizophrenia is a chronic, serious medical disease that can be managed and held a bay for decades. But like all serious medical diseases, there can be an end stage. At that stage, quality of life needs to emphasized.

 

[PsyDr]

Great questions and ideas.

This guy really likes the ALF, doesn't seem like chronic delusions have interfered with him being a resident there for several years. People with schizophrenia live in ALFs around here without POAs or guardians to sign them in.

Family doesn't have a legal document to make healthcare decisions. State law outlines the algorithm for proxy decision makers if the patient lacks capacity. It's spouse, parents, adult children, siblings...something like that. But we have the correct proxy identified per statute. The primary team may be asking him to sign a POA for a family member now, but I'm not sure how that would hold legally. The patient doesn't want a procedure, but willingly consent to abdicate their decision-making authority to someone who will authorize the procedure essentially as soon as the document is signed. I'm guessing he might not fully understand what he's agreeing to.

I'd love to get the pacemaker rep into the hospital on a weekend. Just imagining some good looking 30 something dude. "Sir, let me tell you, this is the best pacemaker on the market, it's got everything!"

1) I’ve had device reps or their helpline (and email) talk to a patient about uncommon issues like “can I SCUBA dive with that battery implanted?”. I could spend an hour of psychotherapy making some guesses about that question, or have a 5 minute phone call that definitively answers it. I was trained in the latter.

2) Then get the family on board, get POA, and don’t worry about it. Academically, if his delusions are guiding the medical decision, he likely doesn’t meet the reasonableness criteria. Pragmatically, no attorney is going to take this case, depose this person, and then present a delusional person in front of a jury.

 

[forchinet121]

1) I’ve had device reps or their helpline (and email) talk to a patient about uncommon issues like “can I SCUBA dive with that battery implanted?”. I could spend an hour of psychotherapy making some guesses about that question, or have a 5 minute phone call that definitively answers it. I was trained in the latter.

2) Then get the family on board, get POA, and don’t worry about it. Academically, if his delusions are guiding the medical decision, he likely doesn’t meet the reasonableness criteria. Pragmatically, no attorney is going to take this case, depose this person, and then present a delusional person in front of a jury.

Exactly why the liability with these cases is very low

 

[WisNeuro]

Exactly why the liability with these cases is very low

If you go through the proper channels, and document well, at least.

 

[forchinet121]

If you go through the proper channels, and document well, at least.

The norm around me is very poor documentation and no one seems to care

 

[Stagg737]

He does not demonstrate understanding of the lethal nature of his heart condition. Actually, in discussing it, he borders dangerously close to attributing the heart condition to his antipsychotic and wanting to stop it to prove to everyone that it's from his meds. He does not think the heart problem could kill him despite education from physicians, believes physicians are lying to him in effort to implant a machine.

Cards says there are no other treatment options, it's pacemaker or cross fingers and hope his heart doesn't stop completely.

Clearly lacks the capacity to refuse the pacemaker, the first bolded section alone is good enough evidence for that. This paragraph documented as is would likely be good enough in court to show a lack of capacity. Imo, this is actually a very straightforward consult. Whether cards should actually do the procedure is a whole different argument.

Keep in mind that this care is life-saving, but the patient is conscious and vigorously refusing the procedure. That changes things v a patient who is, say, unconscious or who lacks capacity but will offer assent.

Doesn't really matter here. The reason for refusing the procedure demonstrates a total lack of capacity. Unless you're talking about whether they should actually do the procedure, but that's not really psychiatry's job.

If this patient demanded to leave, would you place him on a mental health hold, to force him to stay, and cardiology can do the procedure if they choose to do so? There are no medical holds here.

Interesting, I've never heard of a state without medical holds for patients lacking capacity. What do you do when someone is clearly delirious/encephalopathic in the ICU demanding to be let out?

In this case, it would be an eval for capacity to leave which I imagine would yield the same results since he doesn't understand that he could drop dead before he walks out the door. You could argue that his lack of capacity is d/t his mental illness and that he should be held d/t being a direct risk to himself, however if he's at baseline you'd have to make a strong argument that treatment could improve the condition enough to give him capacity, which does not sound like the case here.

I think in this case he lacks capacity, but he also fails the psychological evaluation to have an implanted device and is a very high risk candidate.

This is a great point. We did transplant and cardiac device assessments where I did residency and where I am now and this patient sounds like he'd be a poor candidate at best. Like others have said, if cards were going to go forward with this they'd need a lot of documentation with legal and ethics on board, especially considering he'd be such a poor candidate for surgery.

 

[WisNeuro]

The norm around me is very poor documentation and no one seems to care

That was my experience as well. However, I am the one ultimately responsible for my license, so my capacity evaluations were always very thorough and well documented.

 

[nexus73]

Interesting, I've never heard of a state without medical holds for patients lacking capacity. What do you do when someone is clearly delirious/encephalopathic in the ICU demanding to be let out?

This is a good question. Usually, hospitalist puts them on a mental health hold, which keeps them in house until the next day when the county drops it because delirium/dementia don't qualify for mental health holds per statute. By the time the next day rolls around, the hold is dropped the patient is confused enough to think they have to stay or forgot they want to leave.

You are right, basically the patient lacks the capacity to decide to leave and we just keep him, either with family agreeing or if no family the doctor ends up in the role as proxy. The decision to not discharge becomes someone else's decision if the patient isn't capable. I don't think hospital medicine necessarily formulates it to this extent.

 

[annoyedpsychiatrist]

I agree, all you can do is document his lack of capacity which seems clear given his reasons for not wanting it, and recommend a family meeting and have them all understand risk vs benefit of installing one. I also agree that I would be terrified that he does something extreme if they install it in him, and ultimately the decision should be left to family/ethics committee/etc. But if hes going to die anyways without a pacemaker, then not doing anything leads to an inevitable outcome, whereas doing something he has a chance. In court it would be pretty hard to argue that his treatment team werent acting in his own best interest and that any reasonable physician in that scenario wouldnt have done the same thing.

 

[smalltownpsych]

Capacity is less the issue than compliance with treatment. Sure, you can force it on him, but that doesn’t seem optimal. I would negotiate a bit with the patient, here are your choices, big scary machine or leadless pacemaker. Cant go back to ALF until you make the choice. Which one do you want? Sorry, but saying no to both isn’t an option. Think about it we’ll let you read the brochures and meet with someone who knows about it but it’s going to have to happen. There is an art to getting patients with schizophrenia to agree to things and this is where we shine. It does take time though and we don’t always have that luxury.

 

[FlowRate]

Was around a similar case when I was an intern. The patient was never on my team so I didn't get to know it super well and it's now been almost 7 years since then. Patient with chronic schizophrenia, no family, and bad kidney disease. Occasionally he'd agree to various medications (for psychosis) and to dialysis. But often he'd refuse dialysis. I forget how they actually worked things out, I remember thinking the way the hospital/team had approached the case was wrong, but it's too rusty. It was something wacky like forcing him to get dialysis so they could say he wasn't uremic and then document his decision to refuse dialysis as one made with capacity so they could let him die. Or something crazy like that. But then they still let him do it when he agreed. Extra complicated by him very frequently being quite agitated and often without a lot of warning. The extra weird thing was that he was alive throughout my time on that rotation (2 mo) so it's not like he was super acutely in renal failure. Pretty sure he was still there when I came back to that hospital for my ICU rotation.

 

[aim-agm]

Interesting, I've never heard of a state without medical holds for patients lacking capacity. What do you do when someone is clearly delirious/encephalopathic in the ICU demanding to be let out?

Actually, I don't believe any state has a medical hold for lack of decision-making capacity in general (i.e. not due to mental illness, intoxication, etc.). It is an enormous, but universal, oversight and really we aren't allowed to hold such patients unless they meet the common law standard. The common law standard (at least in my state) is incapacitated + precipitously dangerous, with the index case being a woman in the midst of jumping out of a window to escape imagined pursuers. Many ICU patients could meet this standard, but even if they don't the still usually get held because it would be unethical to do otherwise.

 

[nexus73]

So ethics says do it. Family says do it. Cardiology is planning to do it. Patient is on board to get "a procedure" tomorrow otherwise ALF won't let them return.

 

[Batman's Underwear]

Great questions and ideas.

This guy really likes the ALF, doesn't seem like chronic delusions have interfered with him being a resident there for several years. People with schizophrenia live in ALFs around here without POAs or guardians to sign them in.

Family doesn't have a legal document to make healthcare decisions. State law outlines the algorithm for proxy decision makers if the patient lacks capacity. It's spouse, parents, adult children, siblings...something like that. But we have the correct proxy identified per statute. The primary team may be asking him to sign a POA for a family member now, but I'm not sure how that would hold legally. The patient doesn't want a procedure, but willingly consent to abdicate their decision-making authority to someone who will authorize the procedure essentially as soon as the document is signed. I'm guessing he might not fully understand what he's agreeing to.

I'd love to get the pacemaker rep into the hospital on a weekend. Just imagining some good looking 30 something dude. "Sir, let me tell you, this is the best pacemaker on the market, it's got everything!"

Can he sign POA? I thought POA can only be signed when a patient is at his/her right state of mind. I would ask him whether he is aware that signing POA could result in pacemaker placement.

It is also important to note that lacking a capacity to refuse a procedure does not grant unlimited power for doctor to perform the procedure even if the family member/NOK agrees. Will he immediately or imminently die without the procedure? If not, any prudent lawyer can make counter argument. As people suggested, no can earn immunity from liability. Ethic consult + Interdisciplinary meetings + Family meeting to dilute responsibility. For any complicated capacity consult, primary team will ask "what's next?" after the capacity evaluation. The best and the worst answer is "up to the primary team, ethic team, and hospital lawyer".

 

[annoyedpsychiatrist]

Can he sign POA? I thought POA can only be signed when a patient is at his/her right state of mind. I would ask him whether he is aware that signing POA could result in pacemaker placement.

It is also important to note that lacking a capacity to refuse a procedure does not grant unlimited power for doctor to perform the procedure even if the family member/NOK agrees. Will he immediately or imminently die without the procedure? If not, any prudent lawyer can make counter argument. As people suggested, no can earn immunity from liability. Ethic consult + Interdisciplinary meetings + Family meeting to dilute responsibility. For any complicated capacity consult, primary team will ask "what's next?" after the capacity evaluation. The best and the worst answer is "up to the primary team, ethic team, and hospital lawyer".

Well on a positive side of things, the psychiatrist role here is only determining if the patient has capacity in regards to the question being presented, which the patient does not appear to have capacity. Ultimately the decision to put it is made by the cardiologist/hospital. The psychiatrist is only giving an honest assessment of capacity, so I feel in this situation it would be pretty hard to sue the psychiatrist as we dont say put it in or dont put it in, we just assess whether they have the ability to understand the options presented to them, which in this case, the answer is very apparent. If the patient ever sued the psychiatrist for his capacity eval, he would sure have a hard time finding a lawyer willing to use time/resources to prove that the psychiatrist was at fault by saying the pt had no capacity, when the pts reason for not wanting it sounds like a terminator franchise movie.

 

[WisNeuro]

Well on a positive side of things, the psychiatrist role here is only determining if the patient has capacity in regards to the question being presented, which the patient does not appear to have capacity. Ultimately the decision to put it is made by the cardiologist/hospital. The psychiatrist is only giving an honest assessment of capacity, so I feel in this situation it would be pretty hard to sue the psychiatrist as we dont say put it in or dont put it in, we just assess whether they have the ability to understand the options presented to them, which in this case, the answer is very apparent. If the patient ever sued the psychiatrist for his capacity eval, he would sure have a hard time finding a lawyer willing to use time/resources to prove that the psychiatrist was at fault by saying the pt had no capacity, when the pts reason for not wanting it sounds like a terminator franchise movie.

You would be surprised at how little some lawyers need to go on to pursue a personal injury case. Some of the cases I have been retained in have been laughable, even with video evidence. Remember, most of them don't want to "win" a trial, they merely want the case to be enough of a hassle to prompt a settlement.

 

[SmallBird]

You would be surprised at how little some lawyers need to go on to pursue a personal injury case. Some of the cases I have been retained in have been laughable, even with video evidence. Remember, most of them don't want to "win" a trial, they merely want the case to be enough of a hassle to prompt a settlement.

It's a tough case, I'm sure you could find a lawyer who might go after the opposite decision being made as well. It's not the correct lens to apply to clinical decision making. Do the right thing. Enough with the fearmongering.

 

[Bartelby]

It's a tough case, I'm sure you could find a lawyer who might go after the opposite decision being made as well. It's not the correct lens to apply to clinical decision making. Do the right thing. Enough with the fearmongering.

I don't think either WisNeuro or I were fearmongering. Both of us have stated there is significant liability potential in a situation like this one. I also cited a specific case (Shine v Vega) demonstrating that with poor documentation liability concerns are not just theoretical. I believe both of us advised not fear but careful documentation. No one has advocated any particular course of action in response to fear of litigation, aside from potentially some posters who advise only opining on capacity and avoiding any further engagement on other issues in order to limit exposure to liability.

I totally agree that we should do the right thing clinically and not let our professional lives be governed by fear. Steps like good documentation and seeking consultation in particularly tough cases, though, are the professional liability equivalent of buckling your seatbelt. And just like buckling your seatbelt, you will almost never suffer consequences from failing to do it, but when it turns out you need it it's very helpful 😀.

 

[comp1]

I see this sort of stuff often. Even if the patient was fully conserved with someone else legally making all decisions for them, how exactly are you going to do SURGERY over their objection. There is consent and there is assent. You really do NEED something resembling assent unless the patient is unconscious and it's emergent. How else? You're going to tie the patient down and forcibly anesthetize them while they are screaming and thrashing to not do it? The risk/benefit for this given the potential harm to the patient while forcing such treatment is just not there. This is to say nothing about post-surgical requirements/needs. Feel free to talk to all the lawyers and ethicists you need, but ultimately it comes down to practicality.

 

[WisNeuro]

It's a tough case, I'm sure you could find a lawyer who might go after the opposite decision being made as well. It's not the correct lens to apply to clinical decision making. Do the right thing. Enough with the fearmongering.

As @Bartelby stated, no one is fear mongering. No one ever said "Don't do it!" They merely cautioned that you need to document well and go through the proper channels. So we're more "common sense -mongering."

 

[SmallBird]

As @Bartelby stated, no one is fear mongering. No one ever said "Don't do it!" They merely cautioned that you need to document well and go through the proper channels. So we're more "common sense -mongering."

Fair enough, I think I'm still reacting to your statement about transfer of liability in the event of an adverse outcome. But sure, document well, I agree 🙂