What would you do? (Difficult case)

[whopper]

36 year old guy presents to our hospital for the first time. Has delusions of being a billionaire, having record labels, owning buildings etc. The guy's homeless. Also had a thrombosis and required Warfarin and will need INR checks at least for several months.

Came to the hospital dehydrated, confused (likely due to the dehydration) and with the thrombosis that was treated. We do not know why he was dehydrated. He doesn't remember. I speculate it was the winter months that were very cold and he couldn't find a source of water.

Tried on 3 antipsychotics at high dosages, no benefit. He has no signs or sx of psychosis other than the delusions. ADLs are fine. You can't tell he even has psychosis unless you bring up the delusions. He doesn't want to take meds but they were court-ordered.

So it's possible he has Delusional Disorder, a disorder that doesn't respond well if at all to meds.

Pimozide was tried with no real benefit. It was tried because there is some data with it and delusional disorder. Guy's been in the hospital 40 days. Way too long IMHO and part of it is because the way the inpatient schedule has been, inpatient attendings have rotated on it and left it for the next guy.

So here's the problem. Guy still is psychotic but there's not direct danger from his delusions. Fine. But he cannot pay for his Warfarin treatment and refuses govt assistance because he insists he is a billionaire. Already tried the rational arguments (if you were really a billionaire the gov would either deny you the stuff you don't qualify for, or you would get the stuff anyone even with money could get).

Should this guy be discharged --> and then not be able to afford his Warfarin treatment? He understands and has capacity that needs that treatment.

Or kept in the hospital-possibly indefinitely given that delusional disorder possibly could not be treated with meds?

If kept in, would you up the ante and try Clozapine or ECT given that there's hardly any data showing they work for delusional disorder? What would you do?

And everything you pretty much think of such as labs to see if it was something that could be isolated, collateral (there is none) have turned up nothing of substance.

Keep and treat? Or discharge?

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[heyjack70]

Keep. He is gravely disabled due to his delusions. Delusions are impairing insight into managing his serious medical illness. Which could kill him. I would move to clozapine or ect if he was willing. He'll get better or he won't. This is a state hospital?

 

[birchswing]

I'm a patient and have no advice obviously, but I am curious if you are allowed to find/contact his family to get more history or help for after discharge? Also, how can he afford to stay in the hospital for 40 days? I thought if there wasn't an emergency, people were put out on the street. When I've asked my doctor about going inpatient they've told me it's for 2-3 days max.

Edit: I just read the Wikipedia page on delusional disorder. It sounds identical to what you described: the lack of efficacy of antipsychotics and that the causes are sometimes from social isolation and excessive stress (which I would imagine happens if you're homeless).

I'm curious what would happen if you treated it as an acute stress reaction. Being in a hospital and being homeless both sound pretty awful, although one obviously being better than the other. Are delusions such as this ever protective defense mechanism due to acute stress? If so, maybe the answer is to solve the underlying problems, which you've already tried with getting government assistance. Sounds to me like family could play an important role. I wonder if you were to talk to him about the difficulties and stresses of being homeless what would happen. Is he able to acknowledge those?

 

[benlinus]

1. Don't discharge
2. Do a capacity evaluation(which he will likely not pass; look at 7b of this link below)
http://www.fresno.ucsf.edu/norcal/downloads/nov2_2011Handout.pdf
3. Find a next of kin or a surrogate decision maker
4. Get ethics involved if needed
5. If can't find next of kin/surrogate decision maker then will likely need a state appointed guardian

(Ethics and the medicine team will weigh in on whether this is an immediate life threatening condition and warrants such interventions)


Also do a MOCA evaluation on the patient and get an idea of his cognitive abilities.

http://www.mocatest.org/pdf_files/test/MoCA-Test-English_7_1.pdf

Based on your description of how he presented to the hospital, he doesn't seem to have the ability to adequately take care of himself (thought I'm not familiar with all the circumstances surrounding his admission)

 

[F0nzie]

Your patient has medical decision making capacity and is not acutely dangerous to himself or others. Despite having fixed delusions, he fully understands the consequences of refusing medical treatment for the maintenance of his current condition.

These cases are fascinating because we often see psychotic patients get grounded with meds. However, some delusions simply do not go away with antipsychotic medications. I have a number of chronically delusional patients that have not fully responded. One of my patients believes she is Katy Perry. She always comes to the office with a new smash hit on the radio and because of that her decisions concern me... But legally I cannot keep her locked away for that. So I see her monthly and she receives Invega Sustenna per her court order.

My opinion: Discharge to outpatient psychiatry and medical assertive community services.

 

[DuskPhilosophy]

I agree with Fonzie. How much time went into convincing him he needs government assistance? Is this a situation where the social worker can sit down with him for more than 10 minutes and say "Hey we want to keep seeing you and making sure that you are doing well but to do that we have to get you signed up with insurance, that way you're not wasting any of your billions on treatment." Perhaps seeing him at the county inpatient facility for "check ups and lab work" after discharge might be something he agrees to.

 

[nitemagi]

I might play around with the logic that billionaires stay billionaires because they don't spend money. Like how Warren Buffet still lives in his little 2 bedroom house in Nebraska. If he can go along with that logic, then it makes sense to have the government pay for his meds. Talk to him like he's a republican.

 

[DuskPhilosophy]

http://www.nydailynews.com/new-york...ch-ward-obama-twitter-claim-article-1.2159049

Somewhat relevant...

 

[birchswing]

http://www.nydailynews.com/new-york...ch-ward-obama-twitter-claim-article-1.2159049

Somewhat relevant...

The staff sound incompetent. Even if Obama following her on Twitter were a real delusion, forcing her to admit it sounds petty more than it sounds like treatment. Forcing people to deny delusions also sounds like it would give people incentive to deny them when they in fact still believe them.

 

[heyjack70]

http://www.nydailynews.com/new-york...ch-ward-obama-twitter-claim-article-1.2159049

Somewhat relevant...

Step 1: assure the patient is not, in fact, Martha Mitchell.

Regarding WHopper's post. I disagree with this patient having capacity for medical decision making. Sure he understands the need for treatment, but he is unable to pursue treatment appropriately. What if he said magic unicorns would deliver the Warfarin to his medicine cabinet and refused any other means of getting the medication? The ultimate outcome is the same, he would of course not get the Warfarin because of his delusions, and would end up at risk of dying. I think the trouble is we don't know what this patient will do if discharged. As in, if he gets out and can't get his medication because he is not really a billionaire, will he agree to government assistance then or will his delusional system expand to explain why no one accepts him as a billionaire and continue refusing help. Does this patient deserve a referral to outpatient ACT/PACT? Can you keep him under commitment and monitored as an outpatient so he can be rehospitalized if he is not able to succeed with treatment as an outpatient? Will the patient accept a one month supply of Warfarin from your hospital and further delivery of medication from an outpatient case manager?

 

[Shikima]

Discharge with ACT. Or perhaps have him court ordered to a NH to ensure he is able to get his medications?

 

[hamstergang]

I don't know about other states, but here in NJ at least, you can (and are obligated to) keep someone hospitalized if they are unable to care for their essential medical needs as a direct result of a psychiatric disorder, and there isn't someone outside the hospital who is capable and willing to care for those medical needs. It sounds like here, the delusions prevent the patient from taking his warfarin outside the hospital, so he should remain in the hospital unless the ACT thing can be worked out.

I had a talk once on CBT for delusions, butbdont remember the actual data for its efficacy. He's in the hospital long enough, so can this be tried since meds aren't helping?

 

[wolfvgang22]

Sounds to me that the patient lacks full capacity due to his delusions that put his life at risk.

 

[hamstergang]

This isn't a question of capacity as far as I can tell. The OP states that the patient is not refusing the warfarin. It sounds like he understands that he needs the medication. The delusion only comes in for how he will afford the medication. I guess if he doesn't understand the risks of not taking it, he'd lack capacity, but I see no reason to think this is the case.

 

[michaelrack]

Start proceedings for a guardian/conservator to handle financial and medical affairs. Discharge from psych hospital (perhaps keep in psych hosp a little while to give proceedings a time to begin).

 

[whopper]

I am curious if you are allowed to find/contact his family to get more history or help for after discharge?

We're not allowed to contact his family without permission unless we need info that could help solve an acute emergency.
In Missouri, you cannot send a patient to a state hospital unless that person committed a crime. Yes I know it's stupid but it's what's going on here. The problem then becomes you sometimes get a patient that needs to be in the hospital for months for whatever reason (e.g. Clozapine-needs 2 months to get the right dosage) and the short term units have to eat up the cost.

I already talked about this with several colleagues and we're basically in a damned if you do or don't situation. Most agree he has the capacity to treat his thrombosis and that's the only danger factor, but he doesn't want to get gov assistance and we can't court order him to sign the papers. Getting a guardian could take several several months and then it might not even be allowed cause his lawyer could argue he has capacity.

And then if you keep him, on the logic that his psychosis needs to be treated, we could be doing something unethical because this disorder doesn't respond well to treatment? Forced ECT treatment or Clozapine on a patient with a disorder that will likely not respond to it? That's terrible.

 

[notdeadyet]

I would argue that he meets criteria for grave disability, but that is not based on whether or not he refuses warfarin or psychotropic medications. Medication issues are not grave disability, they are issues of capacity. If medication use was an issue of grave disability, you'd be holding half your hard core drug abusers who came through your door.

But you could make the case for grave disability based on his delusional disorder impairing his ability to find shelter as evidenced by the condition in which he came in and the nature of his delusions. That said, if he's been their 40 days, you've already taken that tact.

My general approach is to ask myself "what further benefit will additional inpatient services provide?" If you don't expect any, looking out outpatient services with assertive care would be the most appropriate choice.

I sympathize. I've had two true delusional disorder cases and made marginal progress on only one of them. With clozapine, for what it's worth.

 

[hamstergang]

I would argue that he meets criteria for grave disability, but it has nothing to do with his refusal to take medications. That is not grave disability, it's an issue of capacity.

Who said he's refusing to take medications? I'm so confused why so many are trying to make this about capacity when it isn't.

 

[kaserm]

With medications not working, perhaps he could have been subjected to psychotherapy- CBT...in his situation, obviously, delusion serves as a shield that protects him from despair...But OK, I guess its too time-consuming.

( Unless he is also suicidal) it baffles me that he can in no way be persuaded into signing papers...along the lines of " government finds its celebrity billionaires way too valuable to leave their health to chance and their good will etc...". But you tried it...

As for capacity...in fact, I would say that precisely his understanding that he needs treatment testifies to his lack of capacity. He wants to take Warfarin but is unable to fully appreciate his circumstances. His autonomy is not at stake here, you are just helping him to get the medications he wants, but otherwise would not get because of delusion.

 

[notdeadyet]

Who said he's refusing to take medications? I'm so confused why so many are trying to make this about capacity when it isn't.

One of the other posters brought up refusing to take medications as a ground for grave disability, which I was disagreeing with. Taking or not taking medications is an issue of capacity, not grave disability.

Sorry my post wasn't more clear. I'll edit it. There's no indication that the patient is refusing to take medications. I don't see any case for the patient lacking capacity in this case. The issue at hand in my eyes is whether his mental illness (delusion) is interfering with his ability to seek and maintain shelter. I believe it is, which makes a case for grave disability. What whopper's scratching his head over is what to do about it. No good answer there.

 

[milesed]

Keep on involuntary admit/ 72 hour hold or whatever your state requires, use ECT, then meds, then he can make decent decisions about his future.

 

[notdeadyet]

I know there is a lot of regional variation in terms of ECT, but I'd have a tough time making a case for it for delusional disorder, particularly with Clozapine not having been tried. Is there any evidence for ECT used for delusional disorder?

 

[wolfvgang22]

This patient is not just a fiscal conservative. The patient is delusional that he is a billionaire. His delusion is preventing him from getting his potentially life saving medication. This can result in death from thrombosis. From what you say, he has no insight to his delusional thinking. A reasonable, non delusional person would not be refusing medication in this patients true financial position. Yes, he has capacity in one sense - he believes he needs the medication. He lacks capacity in the sense that his delusion is preventing him from accessing the resources he qualifies for to actually get the medication. Just because he has capacity in one area does not guarantee he has capacity to make decisions in all areas. This patient lacks capacity in his financial matters and in accessing healthcare, not on whether he needs Warfarin or not. He probably needs a fiduciary guardian. I can't imagine any judge would disagree with that.

 

[wolfvgang22]

Sorry, unintended multiple post

 

[wolfvgang22]

Sorry, unintended multiple post

 

[Armadillos]

Assuming you got the guy his warfarin do you feel safe letting him go as far as his reliability to show up to get his INR checked? Because if you genuinely felt ok about letting him go otherwise, I'm sure there are (borderline ethically shady) ways to get him to sign up for the free meds by using a lot of jargon about what the paperwork he is signing means.

But that being said, sounds like his inability to care for himself by keeping hydrated contributed to his thrombosis in the first place, so seems like this guy has more issues than just thinking he is rich.

 

[Ceke2002]

Is there a street outreach team you could connect with who could perhaps keep an eye on him, at least make sure he's looking after his basic survival needs at a minimum?

 

[Psychobabbling]

#1: I agree with wolfvgang22 - he doesn't have capacity around that decision

#2: Does he need warfarin? Can he switch to a med that doesn't require INR monitoring (could he even appreciate the risk of it not being reversible with vitamin k/ffp). If he does not have thrombotic risk factors, he needs 3-6 months of treatment tops. If it's a DVT or PE, maybe get medicine or whomever on board and re-image the guy. Maybe the clot is gone.

#3: What if you guys found him the BEST place for him to stay, with the BEST staff, BEST outpatient center that is INCREDIBLY excited to have him there....

Reality:
From a standpoint of doing what's right for him, I think you need to keep him.

I also think this is one of those cases where more hands in the pot are helpful. Get the ethics committee involved, etc.

Biggest thing of all - be able to justify whatever. Succumbing to admin IS never the right answer lol

 

[doctorpilgrim]

I agree with wolfvgang22 regarding capacity. The issue here is capacity and the resulting consequence due to not having that capacity to justify his decision to not obtain that medication in a rational basis.
Can a patient refuse life saving treatment on the basis of his irrational belief. This is the point where it becomes an ethical question;Can a patient be kept long term on a mental health unit when the underlying condition that is his delusional disorder may not change with treatment.
Capacity assessment can shed some light on the issue of his ability to survive in an outpatient setting.
That being said as the post above mention,why was he dehydrated, the reason for homelessness etc, each case is so unique in psychological and social aspects that it is very difficult to understand on the basis of limited information. I can only empathize with whopper.

 

[whopper]

Question for all of you who believes he lacks capacity. Do you believe then that he should get ECT or Clozapine? How would you treat this guy? I'm not making this accusation against anyone but bring it up because it has to be addressed. You cannot simply keep someone in a hospital against their will unless there is some type of reasonable plan of care.

So what would that be? Just reiterating that if this is truly delusional disorder, no med is likely going to help. Data with delusional disorder and ECT isn't good.

I will say that to simply keep the guy in the hospital without some type of reasonable care plan is more CYA practice than practice that is respecting the patient's individuality.

By the way I did discharge the patient. New factors happened yesterday and today that IMHO made it feasable though it didn't go the way I wanted it to go, but it went in one direction enough to force my hand for a discharge or keep him to do treatments that I thought would've been worse for him given the lack of data and risk of problems. I'll state what happened in a few days because there'll be too many thought processes going on.

 

[hamstergang]

Question for all of you who believes he lacks capacity. Do you believe then that he should get ECT or Clozapine? How would you treat this guy? I'm not making this accusation against anyone but bring it up because it has to be addressed. You cannot simply keep someone in a hospital against their will unless there is some type of reasonable plan of care.

Capacity has to be discussed in a specific context. I agree with those saying he doesn't have capacity to make financial decisions, and so a fiduciary should be assigned. But that's not really much to do with us, right? I guess we could get the process started but that doesn't help us treat him -- lacking capacity for financial decisions does not in any way inform a treatment option, so trying to link the lack of capacity to ECT or clozapine is misguided.

So what about the CBT suggestion?

 

[whopper]

CBT-won't work or wont' work well (at least IMHO) as he didn't want to do it stating he's a billionaire and he didn't want to work on us convincing him he was not. Further, if you keep talking about a fixed delusion, the data supports you're just going to reinforce it more.

Keeping the patient so he could have a guardian actually IMHO is a viable choice if you keep him and a better choice than forced-treatment for a fixed delusion that has pretty much no to poor data that meds could work on it.

On geriatric units, severely demented patients, all the time, are kept in until they could get a guardian for similar reasons. They lack ability to care for themselves and don't realize it.

 

[F0nzie]

So what about the CBT suggestion?

It's good that you are thinking about CBT for psychosis because there is some evidence for it. But you need to put it in the context of this particular presentation and setting. He has fixed delusions and he is in the hospital. The success rate here for CBT is probably going to be low since he has fixed delusions. Also, there are likely no resources to provide in house CBT. The likelihood of him following up with a psychologist is low because he does not believe he has a mental illness. A referral should be made nonetheless and followed by case management.

Think of the nature of delusions on a spectrum. With paranoia and social anxiety ie. perceiving criticism and judgment from others on the mild end that may be amenable to cognitive reframing vs. believing you are a billionaire when you are in fact homeless. You need to consider the possibility that challenging this patient's false beliefs may irritate him and push him further away from the medical treatment he needs. You should also assess if he even has the cognitive flexibility and insight to tolerate the notion that his fantasy may be a defense for what he is lacking. You are better off rolling with resistance, building the relationship, gaining his trust to address his medical needs-- and if you stick with him for the long haul maybe, just maybe he will let you into his world...if he is even capable of doing so.

 

[wolfvgang22]

This patient's life if at stake due to his delusional thinking in light of his current medical condition. He could die suddenly from a pulmonary thrombosis, or have a debilitating stroke. Ethically, and to avoid malpractice, my duty is to advocate for what I believe is best for the patient's health. I would advocate for court ordered treatment because of his Delusional Disorder causing Grave Disability because of his lack of capacity, and be willing to provide an affidavit to the court to that effect. I would testify the patient lacks insight and judgment due to his grandiose delusion if necessary. The judge will decide if he is competent to manage his medical and financial affairs.

The patient doesn't have to remain inpatient to have a guardian and fiduciary appointed or to be required to participate in required medical and psychiatric treatment, as you know.

If the patient is willing to participate in CBT, great. It is unlikely to harm the patient and may help. If he isn't willing, and he won't be, then I'd avoid it. Anti-psychotic medication is the best option. Clozapine is an option. I don't see the point in ECT, unless there is some evidence I don't know about showing ECT is effective for delusional disorders. Prognosis is guarded, no doubt. I'm wondering if this patient needs neuroimaging, and if he has had a stroke already.

 

[F0nzie]

This thread is reminding me of a great moment I had with my psychodynamic therapy instructor. We were on the subject of the "omnipotent wish" or fantasy. In other words the the false beliefs patients hold on to in a depressed or delusional state that prevent them from grieving losses and moving on. I asked "It takes so long to get to that point in therapy. Is there a 1 liner I can use to get them there so I can help them snap out of it and move on?" Her reply "it seems the patient is not the only one that has the omnipotent wish".

Whopper-- solid work with this patient. You did what was best for this patient to the fullest extent. We need more psychiatrists like you.

 

[heyjack70]

Wow, you must have come up with some support network for him outside the hospital. Or the internist said he doesn't really need the warfarin?

I think he lacks capacity regarding the warfarin therapy because he will not be able to get the medication for himself because of his delusion. There is a nexus between his mental illness and his inability to appropriately engage in care. The fact he can agree he needs the warfarin is moot because he will not be able to get it outside the hospital.

After reading all the other comments I would wait for a guardian, family, or ACT team to follow him closely as an outpatient and assure he gets meds and makes it to INR checks. I disagree with it being CYA medicine to keep him in the hospital. To clarify, I don't think it's just CYA medicine. For arguments sake, if this was a family member of mine with this condition I wouldn't want you to let them out only to stop his anticoagulation or miss INR appointments and die from a embolus or hemorrhage. I think keeping this patient in the hospital, if he cannot engage in treatment, is in his best interest because the risk of missing doses of warfarin could have disastrous consequences. Respecting his individuality is going to sound idealistic if he dies from inability to partake in appropriate care.

 

[whopper]

I would advocate for court ordered treatment because of his Delusional Disorder causing Grave Disability because of his lack of capacity, and be willing to provide an affidavit to the court to that effect. I would testify the patient lacks insight and judgment due to his grandiose delusion if necessary. The judge will decide if he is competent to manage his medical and financial affairs.

Not in Missouri, but in most states you must prove in court that the forced treatment meets specific criteria that none do (as far as I know) with treatment of delusional disorder. Pimozide has some data supporting it but the data that Daubert states require is a double-blinded placebo controlled study. What a Daubert state is is a state that requires high scientific scrutiny with the following criteria.
http://en.wikipedia.org/wiki/Daubert_standard

So, for example, if a patient has delusional disorder, you can't force a treatment even if the patient is dangerous due to the DD unless you can provide enough evidence that the treatment could work.

I'll tell what happened and why I discharged him.
This thread did help in the sense that I did a MOCA on him (if you don't know what it is, it's pretty much a better version of the Folstein MMSE and that the score does have a correlation with ADLs). He got a 29/30. So in short no cognitive problems.

So I asked him....Mr. X, I'm considering possibly discharging you tomorrow. Give me a plan that you could make it out there. He told me he didn't want to go out in the community because he couldn't pay for housing. So I then told him why he wanted to be in the hospital for "assisted" housing but refuse government assistance for his meds. He told me that it was a matter of pride. He told me that he full-well knew that he could not get his money even if he was a billionaire cause he went into several banks and they all kicked him out. He also stated if he could get access to his money the social worker would've figured a way to it while he was in the hospital.

So I told him, something to the effect you 1-you know you can't get your money and 2-you know you need treatment that will cost money you don't have, so 3-why don't you at least sign on for gov assistance so that in the meantime, until you get your financial situation fixed you could afford meds?

Patient told me it was pride. He was not going to accept a handout even if it puts him at risk. He did not see being in the hospital for free as a handout because he was under the commonly held misperception that hospital stay was free, but that he also didn't feel bad about it because while here he offered to clean up tables, assist staff members in holding doors, things like that.

So I told the patient that he apparently had capacity to decide to refuse government assistance and it was not really delusionally driven (though yes he is delusional). It also spiked my speculation that he may have been manipulating his situation to be in the hospital. Several members on the treatment team suspected he was manipulating this refusal to sign Medicare/Medicaid forms to stay in the hospital because he may have figured out that was an element keeping him here. I then told the patient his option was to be discharged or we would be very very aggressive with treatments such as ECT or Clozapine because the only rationale to keep him in the hospital was to treat hmi and that I did not see those treatments as ethical given that the data is weak they'd help him.

I told the patient I wanted him to sign the forms and that I was going to give him a day to reconsider, and I considered discharging him the next day. Next day we had pretty much the same discussion in front of several witnesses including 3 medical students, a resident and the case was discussed inside out with Risk-Management and our unit supervisor who told me I established he had capacity to refuse government assistance because his reasoning was based on pride, not delusion.

Patient still refused to sign the forms.
For further CYA (and because I really don't want this guy to have a bad outcome), I told the patient we would get him a few weeks worth of the meds (we could do that only once per year per patient), we made sure his next appointment with a PCP and psychiatrist would be before his meds would run out. Patient again reiterated he understood he would not be able to get access to his money and that he needed Warfarin and didn't have a way to pay for it.

OK so now I'm feeling better in the sense that I established that 1-he has capacity and 2-his refusal was not due to the delusion but due to his pride being hurt.

And I was thinking we did enough for him to be safe because we got him enough meds to last him.

So I was feeling good in the sense that I did I felt everything we could do that I felt was ethical given that aggressively treating him IMHO was unethical. I also felt confident he would be ok at least until he saw his doctors and if he wasn't going to be able to continue his treatments they could refer him back to the hospital.

OK so fine.....He was discharged. It's a few hours later and I'm reviewing the notes and I find out that the social worker got his meds, gave them to the patient and he refused to take them as he left the hospital.

Now I'm feeling like crap, and I'm pissed. I did the CYA to cover my butt but I don't like what happened one bit. If I were there at the moment, however, I don't think I would've kept him in the hospital. he had capacity. Part of me wonders if his intention was to just go to another hospital.

 

[whopper]

Respecting his individuality is going to sound idealistic if he dies from inability to partake in appropriate care.

Nightmare case that thankfully was not mine while I was at a previous institution.
Gang-banger was shot in the spine during a drug-deal gone bad --> becomes quadriplegic. He was not mentally ill. Not even any PTSD over him being shot. The entire time he's in the hospital he's acting like a sociopathic gang banger with him frequently demanding nurses to "suck my dick so I can see if I can still feel it." and things to that effect.

Despite that he's paralyzed he refuses nursing home care. He said he was going to be a tough guy till the end and die fighting rather than be an invalid in a nursing home.

So he's improved to the point where it's either discharge to the street or nursing home. He was asked dozens of times to go to the NH and yes he had capacity. Psych consult was done. He had capacity.

So it's a few days later, he's moving along in his electronic wheelchair, and his toes and scraping the ground to the point where his dermis is worn-off. People call the police. The kid doesn't give a damn cause he can't feel it and he's telling everyone he's a tough guy. Police bring him to the hospital. He's bandaged up. He again demands to leave. Again refuses everything. Again psych consult says he has capacity.

So it's a few weeks later. He now has sores on his buttocks from sitting down all the time. Brought to the hospital by the police. Surgery is done. They tell psych to take him. Again psych consult is done and he has capacity. He's discharged to the streets.

Over the course of the next few months the last paragraph is what happened several times. It got to the point where one time a surgeon was so pissed off with the situation that after he was surgically cleared he ordered staff members to transfer the patient to the psych unit without the unit's approval telling them that they had no business saying the patient had capacity. Patient was left in wheelchair outside the psych unit door that staff members refused to open for the staff members that were ordered by the surgeon to transfer the patient against hospital protocol.

(Needless to say the above violated several policies).

What ended up happening was the patient ended up finally getting a butt-sore that led to infection and sepsis and then even refused the treatment. He had capacity and ended up dying.

I hate saying this but this case was analyzed on several levels by several departments, the hospital's lawyers, the ethics committee, even local judges were called in to make sure ther wasn't something we could use to get the guy to the NH. Legally you can't force treatment if the patient has capacity even if it goes against their best interests. It's the same reason why people are allowed to smoke and we discharge alcoholics that we know will drink again. AAPL conferences bring up cases like this and they would've too said you would've had to have respected the patient's choices despite how bad they were.

 

[whopper]

Whopper-- solid work with this patient. You did what was best for this patient to the fullest extent. We need more psychiatrists like you.

Don't know given what happened above. I think the only alternative other than what I did was to keep the guy until a guardian could've taken hold.

The reason why I didn't do that was cause I wasn't expecting the guy to refuse the meds when he left (especially when he full well told me he knew he needed the meds), and I honestly didn't think a guardian would've been given because his cognition and capacity were there. One could argue however that we could've at least tried.

But another problem is even if a guardian was approved and the patient discharged, the guardian has no power to control the patient in the community other than to call the police and tell them the patient needs to be sent to the hospital if he doesn't follow the guardian's commands. The patient is young, athletic and likely would've just left any guardian-enforced situation we would've placed on him cause he didn't want one.

Like I said, this IMHO was a no-win situation. I tried the route that I felt would've given him the most amount of freedom while still maintaining a good chance for continued treatment. He walked out on it. He either knew what he was doing and was just going to go to another hospital or knew what he was doing and is going to put his life in needless risk.

 

[birchswing]

Well, the other side of the American dream is the American delusion.

“Socialism never took root in America because the poor see themselves not as an exploited proletariat but as temporarily embarrassed millionaires.”

― John Steinbeck

 

[Shikima]

CBT-won't work or wont' work well (at least IMHO) as he didn't want to do it stating he's a billionaire and he didn't want to work on us convincing him he was not. Further, if you keep talking about a fixed delusion, the data supports you're just going to reinforce it more.

Keeping the patient so he could have a guardian actually IMHO is a viable choice if you keep him and a better choice than forced-treatment for a fixed delusion that has pretty much no to poor data that meds could work on it.

On geriatric units, severely demented patients, all the time, are kept in until they could get a guardian for similar reasons. They lack ability to care for themselves and don't realize it.

I can't help but think, how is this any different than the person from Haiti who believes a spell has been cast upon them and they need help from the witch doctor back in their old community.

 

[heyjack70]

Your hospital staff should call you if a patient is refusing medications at discharge. That's a serious mistake from social work.

 

[F0nzie]

Don't know given what happened above.

The patient made a choice being fully aware of the medical necessity. aka against medical advice.

 

[Psychobabbling]

"There is no escape. Moral risk cannot, at times, be avoided. All we can ask for is that none of the relevant factors be ignored"

 

[doctorpilgrim]

Regarding the capacity question. IMHO part of what whopper did was clarify the capacity in a specific context. I too think that he would have passed a capacity evaluation. I have an almost similar patient who is an outpatient who believes that he owns a large part of United States because a treaty the government signed with him and is followed by ACT team.
Now another question is that if a person refuses life saving treatment on basis of religion, is it any different ethically than refusing it on pride, although here it can be argued that basis of his pride is delusion.
Commitment law is very different in different states, In some states it could be argued that there is reasonable chance that he will not take his medication and put himself in grave danger, fifth standard in states like Wisconsin.

 

[Ceke2002]

On geriatric units, severely demented patients, all the time, are kept in until they could get a guardian for similar reasons. They lack ability to care for themselves and don't realize it.

This is what happened with my Mum, who is thankfully now completely recovered, although it was a case of delerium not dementia. Even when her capacity began to return the Psych registrar at the hospital wasn't willing to reverse the ITO until 1) They were sure she had a guardian (as in legally signed paper work not just someone claiming guardianship), and 2) They were satisfied that I was capable of performing my duties as such. With my knowledge the Nursing co-ordinators, Social Workers, and Doctors were all taking notes on any communication I had with them, including how often I made contact, my capacity to understand my mother's condition and medical needs, my capacity to communicate effectively with medical staff, and so on. It might sound like a breach of her personal liberties, but even if there were any doubts as to her capacity at the time the hospital took the stance of 'patient safety first above all'. I had a quick look at the mental health system in Missouri, and unless I missed something, it sounds as if the system failed your patient, not you. I think you did all you could, which is more than what a lot of Doctors in the same circumstance might have done. Don't be too hard on yourself, your dedication to your patients well being is more than clear from the posts I've seen from you on here.

 

[wolfvgang22]

Regarding the capacity question. IMHO part of what whopper did was clarify the capacity in a specific context. I too think that he would have passed a capacity evaluation. I have an almost similar patient who is an outpatient who believes that he owns a large part of United States because a treaty the government signed with him and is followed by ACT team. Once in a while goes into banks to demand his share, our agreement is that he will not use force, he has stood by it.
Now another question is that if a person refuses life saving treatment on basis of religion, is it any different ethically than refusing it on pride, although here it can be argued that basis of his pride is delusion.
Commitment law is very different in different states, In some states it could be argued that there is reasonable chance that he will not take his medication and put himself in grave danger, fifth standard in states like Wisconsin.

Religious beliefs like voodoo or Jehovah Witness, etc are not considered delusions at all so long as they pretty much conform with others with like beliefs. It is pretty arbitrary and based on the culture the patient belongs to.

 

[Shikima]

Religious beliefs like voodoo or Jehovah Witness, etc are not considered delusions at all so long as they pretty much conform with others with like beliefs. It is pretty arbitrary and based on the culture the patient belongs to.

The country club culture?

 

[birchswing]

The country club culture?

There was a scene that referenced the cultural phenomenon in the movie Side Effects. A man was seeing a ghost of his dead brother and one of the doctors thought it was psychosis but the psychiatrist recognized it as being culturally normal during the grieving process for where the person was from.

One interesting one is eating clay during pregnancy. It happens in some areas of the South in the US. It's even sold in 7/11 type stores for pregnant women in the South. It's some sort of culturally normal thing. I think it's also common in some parts of Africa. I can't remember why it's done, but it's done and normal for those people, whereas if a person who wasn't from a culture that ate clay suddenly started to, it might be a bit abnormal.

 

[whopper]

Your hospital staff should call you if a patient is refusing medications at discharge. That's a serious mistake from social work.

Agree but I honestly don't know if I would've kept him in. One of my bosses told me this is a type of situation where intelligent and experienced psychiatrsits would disagree on what to do. I wouldn't have faulted someone for keeping him in, but I do think he did meet capacity requirements. I'm sure people I do respect would've not done what I did.

I didn't like this case at all. No matter what I did I wouldn't have liked it.