- Psychiatric Times Vol 28 No 11
- Volume 28
- Issue 11
You Say “Yes,” I Say “No,” You Say “Goodbye,” and I Say “Hello”
In theory, psychiatrists possess no special skills for determining capacity of a patient to accept or refuse medical care, yet a large percentage of a psychosomatic physician’s work nonetheless involves capacity evaluations.
The patient who refuses to remain in the hospital presents one of the most commonly encountered clinical and ethical dilemmas in psychosomatic medicine. Decisional capacity is often the crucial factor in determining whether a patient can legally and ethically leave the hospital against medical advice (AMA). Decisional capacity is also a critical aspect of evaluating refusals of treatment and placement.
In this article, we review the literature on assessing the capacity to refuse. We then identify some common pitfalls in conducting these evaluations, and offer a practical algorithm for approaching patients who are adamant about leaving the hospital AMA.
CASE VIGNETTE
Mr S, a 70-year-old chef with chronic hyponatremia and hypertension, is admitted for altered mental status after becoming disoriented and taking all his clothes off during an appointment at the urology clinic. His family reports several “spells” of confusion, dizziness, and reduced ability to ambulate over the previous weeks, raising concern that Mr S is unable to care for himself.
Mr S demands to leave the hospital in the middle of the night AMA and says he will not return or seek medical care anywhere else, no matter how ill he becomes. He has said several times that he just wants to “go home and watch TV because there he has his water jugs and all he needs around him.”
Mr S denies any suicidal ideation, intent, or plan and has no other psychiatric history. He is oriented to person, place, and time; is able to draw a clock; and scores a 26 out of 30 on the Mini-Mental State Examination (MMSE). Despite Mr S’s mental status examination performance, the medical resident is afraid to let him leave because he thinks Mr S is delirious and at risk for a seizure. The resident presents the case to the attending who states, “I am not paternalistic. People have a right to go home and die.”