guardianship

[Attending1985]

I know the discussion regarding disability opinions on patients has been discussed on here before. I am being asked to fill out an examiner's statement regarding guardianship for a patient with SMI. Does this fall under the same rules as disability opinions with the AMA recommending these evaluations and opinions be submitted by an independent examiner?

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[Armadillos]

I’m not an expert on this and have only done it once or twice, but in my state seems the form is standardized from the court and the court is the one who appoints the medical examiners (presumably based on family identifying you as a treating physician), so if you get one in my state doesn’t seem you have a ton of choice unless you want to go argue with the probate court.

 

[calvnandhobbs68]

I know the discussion regarding disability opinions on patients has been discussed on here before. I am being asked to fill out an examiner's statement regarding guardianship for a patient with SMI. Does this fall under the same rules as disability opinions with the AMA recommending these evaluations and opinions be submitted by an independent examiner?

Do you agee that the patient would benefit from a legal guardian? Then just fill out the expert eval forms unless you really don’t know the patient well. Why put the family through the hassle of trying to find and pay for a whole different psychiatrist who will probably claim that they can’t make a decision anyway based off of only one interview.

It’s usually the opposite for me, I’m often trying to encourage families to seek guardianship and find someone actually willing to be the guardian for someone with intellectual disability or severe mental illness.

 

[Attending1985]

Do you agee that the patient would benefit from a legal guardian? Then just fill out the expert eval forms unless you really don’t know the patient well. Why put the family through the hassle of trying to find and pay for a whole different psychiatrist who will probably claim that they can’t make a decision anyway based off of only one interview.

It’s usually the opposite for me, I’m often trying to encourage families to seek guardianship and find someone actually willing to be the guardian for someone with intellectual disability or severe mental illness.

I’ve only seen this patient twice. I’m not crazy about taking anyone’s rights away especially someone I barely have any experience with. Its not family who’s asking for guardianship it’s the county.

 

[PsyDr]

The AMA's opinion is about forensic issues, not just disability. This is based upon their review of the law and professional guidelines. For example, the american academy of psychiatry and law's ethics guidelines state that,

" Treating psychiatrists should therefore generally avoid acting as an expert witness for their patients or performing evaluations of their patients for legal purposes. "


Some references:

American Academy of Psychiatry & Law (2005) Ethics Guidelines for the Practice of Forensic Psychiatry

Hales, R. E., Yudofsky, S. C., & Gabbard GO. (editors) (2008). The American Psychiatric Publishing Textbook of Clinical Psychiatry, Fifth Edition. American Psychiatric Publishing

Melhorn, Talmage, Ackerman, and Hyman. AMA Guides to the Evaluation of Disease and Injury Causation, Second Edition. 2013. American Medical Association.

Reid WH. Treating clinicians and expert testimony. Journal of Practical Psychiatry and Behavioral Health, March, 1998, 4:121-123.

 

[calvnandhobbs68]

I’ve only seen this patient twice. I’m not crazy about taking anyone’s rights away especially someone I barely have any experience with. Its not family who’s asking for guardianship it’s the county.

If you don't feel that you know the patient well enough to fill out the expert evaluation forms, then just say so and see what the probate court says.

The post above is all well and good until you have severely schizophrenic patients in your community clinic or severely intellectually disabled patients who obviously need guardians. What's really in the patient's best interest then, saying they have to go wait and find some other psychiatrist who doesn't really know them or filling out the forms because you know the patient best and you're probably going to ultimately get the best treatment that way when their guardian can just sign them into the hospital when need be instead of going through repeated 72 hour holds and discharges?

If you're not crazy about taking anyone's rights away, you probably shouldn't work doing ED evaluations anymore. I wouldn't use this as a blanket reason to be resistant to filling out expert eval forms for guardianship.

 

[comp1]

Guardianship issues are pretty state specific. Here, you often can't get a mental health guardian placed outside of an inpatient psych unit. Dementia/developmental disabilities can be done outpatient. In general, I'll agree with the above comments that say your choices really are to fill it out accurately or tell the county that you don't know the patient well enough to fill it out. There's no ethical breach here. One could argue that disability paperwork might be in opposition to our recovery model, but's hard to argue that for mental health guardianships, most of which are temporary and designed to get the patient more intensive help. Might it strain your relationship with the patient? Maybe, but for most SMI patients requiring a guardian, they are too stressed by their symptoms to devote a lot of time to harboring a grudge against the physician who provided information to the county.

 

[Attending1985]

If you don't feel that you know the patient well enough to fill out the expert evaluation forms, then just say so and see what the probate court says.

The post above is all well and good until you have severely schizophrenic patients in your community clinic or severely intellectually disabled patients who obviously need guardians. What's really in the patient's best interest then, saying they have to go wait and find some other psychiatrist who doesn't really know them or filling out the forms because you know the patient best and you're probably going to ultimately get the best treatment that way when their guardian can just sign them into the hospital when need be instead of going through repeated 72 hour holds and discharges?

If you're not crazy about taking anyone's rights away, you probably shouldn't work doing ED evaluations anymore. I wouldn't use this as a blanket reason to be resistant to filling out expert eval forms for guardianship.

I don’t do ED evaluations. I work in an outpatient clinic.

 

[Stagg737]

I’ve only seen this patient twice. I’m not crazy about taking anyone’s rights away especially someone I barely have any experience with. Its not family who’s asking for guardianship it’s the county.

Obviously this will vary by locale, but where I'm at if the county or state is asking for guardianship it means the patient probably needed a guardian years ago.

The AMA's opinion is about forensic issues, not just disability. This is based upon their review of the law and professional guidelines. For example, the american academy of psychiatry and law's ethics guidelines state that,

" Treating psychiatrists should therefore generally avoid acting as an expert witness for their patients or performing evaluations of their patients for legal purposes. "


Some references:

American Academy of Psychiatry & Law (2005) Ethics Guidelines for the Practice of Forensic Psychiatry

Hales, R. E., Yudofsky, S. C., & Gabbard GO. (editors) (2008). The American Psychiatric Publishing Textbook of Clinical Psychiatry, Fifth Edition. American Psychiatric Publishing

Melhorn, Talmage, Ackerman, and Hyman. AMA Guides to the Evaluation of Disease and Injury Causation, Second Edition. 2013. American Medical Association.

Reid WH. Treating clinicians and expert testimony. Journal of Practical Psychiatry and Behavioral Health, March, 1998, 4:121-123.

I have a hard time agreeing with the bolded from an ethical standpoint when it comes to guardianship. If I've been seeing a patient for a while and understand their condition and situation well and it's obvious they need guardianship, I'd argue that it violates the principle of beneficence to force whoever is seeking guardianship to attempt to find someone else to evaluate them which will cost extra time and money. Especially when that evaluator likely won't be able to describe the reasons guardianship is needed as well as I could. One could argue that guardianship itself is a violation of autonomy, but if I were going to seek guardianship for someone, it would almost certainly be because they no longer have autonomy over themselves, so it would be a moot point.

 

[PsyDr]

Obviously this will vary by locale, but where I'm at if the county or state is asking for guardianship it means the patient probably needed a guardian years ago.



I have a hard time agreeing with the bolded from an ethical standpoint when it comes to guardianship. If I've been seeing a patient for a while and understand their condition and situation well and it's obvious they need guardianship, I'd argue that it violates the principle of beneficence to force whoever is seeking guardianship to attempt to find someone else to evaluate them which will cost extra time and money. Especially when that evaluator likely won't be able to describe the reasons guardianship is needed as well as I could. One could argue that guardianship itself is a violation of autonomy, but if I were going to seek guardianship for someone, it would almost certainly be because they no longer have autonomy over themselves, so it would be a moot point.

Well, it’s your opinion against multiple professional associations.

 

[Old&InTheWay]

" Treating psychiatrists should therefore generally avoid acting as an expert witness for their patients or performing evaluations of their patients for legal purposes. "

Well, it’s your opinion against multiple professional associations.

If you read the entire statement from your quote above, you would see that they specifically address guardianship as an unavoidable “dual role” situation. When you think about it, completing guardianship paperwork is not very different then going to court to have someone committed; and I assume you would not suggest that psychiatrists should avoid participating in civil commitment hearings, correct?

Also, ethics are guiding principles meant to be considered. Professional bodies can help provide guidelines that can help guide you to an acceptable answer, but they’re not rules to be followed blindly.

 

[PsyDr]

If you read the entire statement from your quote above, you would see that they specifically address guardianship as an unavoidable “dual role” situation. When you think about it, completing guardianship paperwork is not very different then going to court to have someone committed; and I assume you would not suggest that psychiatrists should avoid participating in civil commitment hearings, correct?

Also, ethics are guiding principles meant to be considered. Professional bodies can help provide guidelines that can help guide you to an acceptable answer, but they’re not rules to be followed blindly.

I would suggest that attending psychiatrists be aware of the standards put forth by their own profession. I would also suggest that if one decides to deviate from professional standards (that readily accessible to the legal profession), that they should do so in a manner that acknowledges the existence of said standards and explains why a reasonable minority would do the same.

There is a significant difference unaware of things, and explaining why things don’t specifically apply in a situation. The former could be considered negligence, the latter could be a reasonable minority defense to med malpractice.

 

[nexus73]

I would suggest that attending psychiatrists be aware of the standards put forth by their own profession. I would also suggest that if one decides to deviate from professional standards (that readily accessible to the legal profession), that they should do so in a manner that acknowledges the existence of said standards and explains why a reasonable minority would do the same.

There is a significant difference unaware of things, and explaining why things don’t specifically apply in a situation. The former could be considered negligence, the latter could be a reasonable minority defense to med malpractice.

I think your perspective is a bit draconian. Are you ignoring ignoring the line that guardianship and other evaluations may require a dual role that is unavoidable?

From the AAPL ethics guideline: "In situations when the dual role is required or unavoidable (such as Workers’ Compensation, disability evaluations, civil commitment, or guardianship hearings), sensitivity to differences between clinical and legal obligations remains important."

The differences remain important, but clearly the professional society recommendations recognize several situations where a psychiatrist would be doing a legal evaluation for a patient they have treated, and suggest this is not inappropriate, but rather the evaluator must be sensitive to the varying obligations owed to the patient. I don't see how doing this is "deviating" from professional standards.

 

[Old&InTheWay]

I would suggest that attending psychiatrists be aware of the standards put forth by their own profession. I would also suggest that if one decides to deviate from professional standards (that readily accessible to the legal profession), that they should do so in a manner that acknowledges the existence of said standards and explains why a reasonable minority would do the same.

There is a significant difference unaware of things, and explaining why things don’t specifically apply in a situation. The former could be considered negligence, the latter could be a reasonable minority defense to med malpractice.

I agree with this, but you have to admit it is a little funny coming from someone who didn’t even read or understand the entirety of the guidelines they cited.

 

[Armadillos]

Who are you responding to?

Psydr sorry I quoted you by accident

 

[Armadillos]

The AMA's opinion is about forensic issues, not just disability. This is based upon their review of the law and professional guidelines. For example, the american academy of psychiatry and law's ethics guidelines state that,

" Treating psychiatrists should therefore generally avoid acting as an expert witness for their patients or performing evaluations of their patients for legal purposes. "


Some references:

American Academy of Psychiatry & Law (2005) Ethics Guidelines for the Practice of Forensic Psychiatry

Hales, R. E., Yudofsky, S. C., & Gabbard GO. (editors) (2008). The American Psychiatric Publishing Textbook of Clinical Psychiatry, Fifth Edition. American Psychiatric Publishing

Melhorn, Talmage, Ackerman, and Hyman. AMA Guides to the Evaluation of Disease and Injury Causation, Second Edition. 2013. American Medical Association.

Reid WH. Treating clinicians and expert testimony. Journal of Practical Psychiatry and Behavioral Health, March, 1998, 4:121-123.

As this thread was specifically and easily identified as about guardianship, why did you intentionally cut your quote from the professional recommendations to leave out literally the next sentence which completely contradicts what you seemed to be attempting to imply with the quote you provided? That sort of intentional dishonesty through omission is not helpful for the trainees here.

Here is the next sentence for any confused residents.

“In situations when the dual role is required or unavoidable (such as Workers’ Compensation, disability evaluations, civil commitment, or guardianship hearings), sensitivity to differences between clinical and legal obligations remains important.“

 

[PsyDr]

@Armadillos @nexus73 @Old&InTheWay

1) The aapl guidelines that I specifically quoted had the word “generally”. It’s an important word.

2) I offered citations. Literally no one else did the same. Hopefully everyone was aware of these citations before I said anything.

3) I’ll also point out that the only position I took was for people to be aware of the literature in their own profession, and to have a rationale if they choose to deviate.

 

[Bartelby]

I think it helps to consider the *why* behind avoiding a dual role. An expert witness should have a duty only to the truth. Having a duty to the evaluee (which is the case when they are your patient) creates a conflict of interest; the truth may not be helpful to the evaluee.

In the case of guardianship it is unlikely that the patient is seeking it for secondary gain. Sometimes family may want guardianship to exert control over or exploit the patient, but in general if they seem seriously ill and appear to have a genuine need for guardianship then their interest (even if not their stated desire) and the truth line up. I think you can therefore reasonably proceed, even though I agree in principle that you should be very wary of the dual role.

Of course if you do not know if the patient meets legal criteria for guardianship then you should not be testifying to that whether you are treating them or not!