Question regarding self-harm, capacity, med-psych etc.

[witzelsucht]

This is probably not allowed, but I'm at my wits' end and I don't know where to turn (in this homework assignment for residency). Any response or PM would be greatly appreciated. I'm an EM resident, FWIW.

Patient X is 60F with undiagnosed but floridly obvious OCD, eating disorder, alcohol abuse. We're talking near-Howard Hughes OCD stuff. Fell and broke hip in a drunken stupor the other night. She essentially lives alone, relatives are out of state, husband works a lot. Operative repair, getting tee'ed up for discharge. PT recommending home with in-home PT, no rehab recommendation despite out of state family via phone saying she will overextend herself and hurt herself at home. Refusing home nursing (no dirty outsiders in home). No carpets or surfaces in the home, everything is tile or hardwood (so it can be sterilized). All stairs are polished hardwood with no carpet runners. Wears slippery socks all the time no shoes in the house. Patient refuses to see psychiatrist (they're just a bunch of sex fetishists who want to hear about people's sex life) when family begged her to go in the past. How does one approach this situation? Beg hospitalist for inpatient psych consult? Let's say the patient is on a teaching service, I feel like the resident would be allowed to field calls from a concerned family member, but would it be appropriate to consult a Liason-consultant psychiatrist based on "she's a closet drunk with OCD who is going to mop the floors all day with a post-op-day 3 hip?" coming from an out of state family member? What's the answer? Intervention?

Help. Please.

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[clausewitz2]

This is probably not allowed, but I'm at my wits' end and I don't know where to turn (in this homework assignment for residency). Any response or PM would be greatly appreciated. I'm an EM resident, FWIW.

Patient X is 60F with undiagnosed but floridly obvious OCD, eating disorder, alcohol abuse. We're talking near-Howard Hughes OCD stuff. Fell and broke hip in a drunken stupor the other night. She essentially lives alone, relatives are out of state, husband works a lot. Operative repair, getting tee'ed up for discharge. PT recommending home with in-home PT, no rehab recommendation despite out of state family via phone saying she will overextend herself and hurt herself at home. Refusing home nursing (no dirty outsiders in home). No carpets or surfaces in the home, everything is tile or hardwood (so it can be sterilized). All stairs are polished hardwood with no carpet runners. Wears slippery socks all the time no shoes in the house. Patient refuses to see psychiatrist (they're just a bunch of sex fetishists who want to hear about people's sex life) when family begged her to go in the past. How does one approach this situation? Beg hospitalist for inpatient psych consult? Let's say the patient is on a teaching service, I feel like the resident would be allowed to field calls from a concerned family member, but would it be appropriate to consult a Liason-consultant psychiatrist based on "she's a closet drunk with OCD who is going to mop the floors all day with a post-op-day 3 hip?" coming from an out of state family member? What's the answer? Intervention?

Help. Please.

If she can articulate that yes, there is a good chance she is going to fall at home and injure herself again if she declines any intervention but she doesn't care and wants to go home on her terms regardless, capacity is not an issue. She is not articulating obviously psychotic reasons for not wanting people in her home. Your institution might want a psychiatrist to write a note saying this, but this doesn't even seem like a hard call as far as a capacity evaluation goes, albeit a deeply cruddy situation that everyone involved in her care is going to feel bad about.

 

[Shikima]

It's a similar case where someone is walking around being psychotic and is refusing treatment. Some things you can't do but to educate and document that you've educated. Eventually, she'll return and you'll put humpty dumpty back together again.

 

[clausewitz2]

It's a similar case where someone is walking around being psychotic and is refusing treatment. Some things you can't do but to educate and document that you've educated. Eventually, she'll return and you'll put humpty dumpty back together again.

I am sure laws vary from state to state on this, but in PA it would be so much easier if she was frankly psychotic and refusing home health because she felt they were Soviet agents setting up traps to disintegrate her. Inability to maintain her own safety at home due to acute symptoms of her psychiatric illness. As a practical and ethical matter I would not feel great about forcing this on her and I am sure the home PT people don't want any part of a client who is not going to be interested in cooperating, but one of those home safety assessments with some environmental modifications could probably be mandated.

As is, though, "strangers are dirty and I don't like them, go away" doesn't leave you with much to work with.

 

[WisNeuro]

I would imagine the question is whether or not this person meets the definition of a vulnerable adult, not enough info to make the call here, and can be tricky sometimes even with a lot more info. In the case that she is, self-neglect is still a mandated reporting situation in most jurisdictions. Call APS for a consult and document would be my thought there without further info to rule some things in or out.

 

[nexus73]

I'd push PT to change their recommendation to a SNF/rehab explaining the problems above.

 

[Liquid8]

I think a C/L referral can be justified. You're mainly after diagnostic clarification and treatment re: OCD - if this gets treated, perhaps resistance to the discharge plan will reduce (although in practice, it can take months for medications to take effect). You might also have questions about the alcohol issues and capacity too.

In addition, a discharge planning meeting with the physio and the patient's next-of-kin is also something I'd think about. She's got a husband, and he may be able to clarify the safety concerns voiced by the other relatives or help convince her that having a physio over isn't such a bad thing. Physio may offer alternatives, but if it's determined that she has the capacity to refuse treatment and she continues to do so you will probably be looking tat discharging her against medical advice.

 

[smalltownpsych]

She has the right to refuse treatment. The only other option in this state would be involuntary commitment or guardianship. She doesn't sound like she would meet criteria for either. There is no risk of imminent harm or evidence that her mental illness would lead to a rapid deterioration of her condition that would preclude her from caring for herself. At most it sounds like she is likely to fall again and reinjure herself. I would still appreciate a consult on this case though because you never know when the patient is ready to make a change and also you demonstrated that you made the attempt to address the psychological factors and when she comes back in call me again. Might have more success when patient is confronted with their own inability to adequately care for them self. How to set me up for the consult is key. I hate the "you just need to talk to this person before you can go". Much better is "I know you say you'll be fine, but I'm worried about you and it would reassure me if you just talked to the doc."

 

[Dharma]

Any service can perform a capacity eval. Do that first, then think about consulting psychiatry if you feel there is an underlying (acute) psychiatric issue at hand (outside of delirium if you haven't picked up on that yet). Frustrating when services have the notion that only psychiatry performs capacity evals. (Not saying you are doing that). If you do need psych for a capacity, then go with them and learn. Best of luck.

 

[MLT2MT2DO]

I think a C/L referral can be justified. You're mainly after diagnostic clarification and treatment re: OCD - if this gets treated, perhaps resistance to the discharge plan will reduce (although in practice, it can take months for medications to take effect). You might also have questions about the alcohol issues and capacity too.

In addition, a discharge planning meeting with the physio and the patient's next-of-kin is also something I'd think about. She's got a husband, and he may be able to clarify the safety concerns voiced by the other relatives or help convince her that having a physio over isn't such a bad thing. Physio may offer alternatives, but if it's determined that she has the capacity to refuse treatment and she continues to do so you will probably be looking tat discharging her against medical advice.

If capacity isn't in question how are you justifying a psych consult when the patient has already said she doesn't want to see psych? The only way this is appropriate is if someone needs further help determining capacity.

In addition have you gotten an ROI to talk to family about discharge planning?

I feel like in your answer you've already decided this lady does not have capacity to make her own decisions.

If capacity is intact this is not a psych case for the simple fact the patient doesn't want it to be a psych case. This is a social work case which other specialties tend to think are psych cases

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