Competency

February 5, 2004 Competency

Today’s learning experience in psychiatry can be summed up in one word: competency. We were consulted on two patients. We were asked to determine whether they were competent enough to make medical decisions.

This pt. is an 88 year-old black female who has suffered 2 strokes in 2003. In Jan .2004, Home Health called EMSA and asked them to take the patient to the Emergency Room because herb lood pressure was elevated. More importantly. Her speech was slurred. This pt. had been living on her own all this time, by herself, with someone coming in to help her with groceries

The pt was admitted to our hospital a week earlier. Psychiatry was called to assess the competency of the pstient. I found her in her bed talking to an empty room. When I asked her any questions, she would answer but then she would keep talking.

Finally, I asked her if she knew why she was in the hospital. She said she knew she had a stroke. She emphatically communicated to me she did not want to go to a Nursing home. She wanted to go home, she said. When I asked her why she had refused to take injections. She got a bit agitated. She said that her doctor thought she was crazy. He was trying to give her medicine like Haldol for being crazy, but she was not crazy. She said she wanted to gone home.

Question: Is this woman competent? If we decide she is incompetent to make decisions, then we must release her to home. If on the other hand we decide she is incompetent She will be forcibly administered Haldol. What are we to do?

This case raises the question of whether an elderly person who is not choosing well is necessarily incompetent. She may not necessarily be choosing wisely. She also may not be the smartest kid on the block. However, all of us perhaps know some cantankerous old folks, fiercely independent who live life on their own terms. When do we infringe upon their autonomy?

I learned from my attending that one asks several questions, such as

Do you understand your illness, that you are sick and in need of treatment?

Can you understand the treatment options, their associated risks and benefits and what they mean?

Can the patient hold the information needed to make a medical decision in their minds in an orderly and rational fashion?

If the answer to any of these questions are ‘no’, then the patient is deemed non-competent to make their own medical decisions. It is, of course, highly subjective

Our second competency case was a 46 year old Caucasian male. He appeared highly intelligent but somewhat bizarre in behavior. He spoke with stilted speech and during the course of the interview would go from being friendly to clamming up and withdrawing from giving more information. When asked about medical issues, he answered, “I think it is personal” and would volunteer no more information. He used the same words and answer to several subsequent questions (preservation). If we changed the topic and asked about something else, he would answer in short sentences. If we talked about sports or astronomy (his interest), he would thaw out, but only a little. Lately, he had been refusing medications. When asked about it, he denied he had done so. My attending found him non-competent to make medical decisions.<

Both the above patients lost their autonomy in the hospital setting and would now have little or no choice in their medications, perhaps need to be restrained if they became uncooperative. I shall keep following the case to see if their consciousness resolves and they regain their competence

A case worker for the first case told me that if a person is found non-competent, then a state body called Adult Protection Services comes in to protect them from themselves. They may be placed in a group or nursing home. The philosophical ramifications of today’s experience were immense and gave me a lot to think about.