An Elderly Woman Who Refuses Treatment

by Chandrakant Patel | April 12, 2012 1:22 PM EDT

So far, Mrs. E does not show much recognition of her illness, and any of benefits of treatment. She therefore lacks the capacity to direct her health care, esp psychiatric care.

The first thing to do is to educate her and also acknowledge her life-long preferences. Uness her depression is severe enough (description does not support much intensity to her depression), treatment should begin with establishment of a rapport.

If Mrs. E is compromised in minimum safety or self care due to psychological symptoms, she needs to be treated more aggressively: hospitalization and a second opinion should be sought without losing much time.

Unless I know the caretakers adequately, I hesitate to be party to giving medications under disguise.

by Farrel Klein | April 12, 2012 12:05 PM EDT

In my state, the legal requirement for emergency certification and involuntary medication is that a patient has to have a mental disability, and, as a result of this disability, the patient's unsupervised presence is likely to cause a substantial risk to self or others. Unfortunately, without a guardian, we see lots of family appeals for care in such cases, but the law ties our hands.

by Anthony Ng | April 12, 2012 11:49 AM EDT

Another interesting twist is one that I have encountered before. At what point does one say patient cannot make decision or they are making bad decisions and that emergency guardianship may be warranted. This happens fairly regularly in a medical setting, especially in the elderly.

In response to your question Abigail, I am assuming that this pt is stil her own guardian. As such, we would need permission to talk to her daughter unless there is an overriding concern for safety. Even if the idea suggested by the daughter is good, I may not be able to give it as the pt may refuse. If that is the case, I would ask for a quick meeting with the pt, the daughter and perhaps social service to discuss reasoning and alternatives.

by Abigail Dahan, MD | March 30, 2012 12:22 PM EDT

Seth, and everyone else in this discussion, how far would you go with the "you'll thank me later" philosophy? Take for example if this case developed in the following way:

The patient's daughter (previously unknown) calls you and asks that you prescribe liquid fluoxetine which the home health aide would surreptitiously slip into the patient's food. The daughter hopes that this intervention would help her mother's depression and recently increasing irritability. What would you do then?

by Seth Flesher | March 24, 2012 2:40 PM EDT

I'm not sure what you want to discuss, unless you begin to go through the four competence model and give possible answers everything is theoretical. It would be foolish to waste time guessing possibilities until you've learned more information. She might be a famous researcher in depression studies or she may think the hospital is trying to poison her.

Without more information this is just an exercise in how to determine capacity. What would be more interesting is if you gave us some possible scenarios. What are the tricky answers that patients give? How much decision making is guided by the "you'll thank me later" treatment philosophy in psychiatry. The idea that we know what is best and afterwards the patient will be grateful we did what we thought was right. I am not denigrating this philosophy, I've employed it at times, all psychiatrists have.