While working in the psych emergency room at San Francisco General Hospital, I take a call from my medical colleague, Dr. Jones, toiling away in the "regular" Emergency Department.

"Paul, I'm gonna need your help on this one," she says.

"Okay," I say.

"It's an 80-year-old woman with a pretty severe left leg cellulitis bordering on phlebitis who isn't even letting us draw blood on her when in fact she needs IV antibiotics and a surgical evaluation."

"Is she demanding to leave?"

"Not yet."

"How agitated is she?" I ask.

"Not very," says Dr. Jones. "It's a tough case as it isn't clear she's out-and-out paranoid or delirious or demented. She's just a bit crotchety, hard to talk sense to."

"I take it the loss of her life or her leg is not imminent?"

"No, not yet, at least, but it's hard to say how things will play out over the next 24 to 48 hours."

"Okay, I'll be over in five to ten." (Minutes, that is.)

Dr. Jones is an experienced and savvy attending physician in the ED. If she'd been inexperienced, she might have asked, "Can you come over here and put this lady on a hold so we can draw her blood and start IV antibiotics?"

"Not so fast," I'd have to answer.

ER psychiatrists do assess whether patients meet involuntary hold criteria on psychiatric grounds, which in most jurisdictions include suicide risk, violence risk, and inability to care for self due to psychiatric symptoms, and they can detain patients against their will (for up to 72 hours in California). But the placing of a psychiatric hold can only physically keep a patient in the hospital. It does not have any bearing on whether a patient is competent to make decisions about his or her medical treatment.

In the worlds of emergency and consultation-liaison psychiatry, a medical physician's request for a psychiatrist to assess a patient's decision-making capacity is relatively common.

What would a reasonable person decide? That is the essence of both ethical and legal issues. Competency to make decisions regarding medical treatment in non-emergent situations is determined by a judge or hearing officer in a court of law. The psychiatrist's assessment of capacity is just one of many variables considered by the court in such matters.

This overarching question is complicated by several other ones: How dangerous is the condition? How treatable is the condition? How invasive or harmful are the proposed treatments? How well have the risks and benefits of both not treating versus treating the condition been explained to the patient? What sorts of psychiatric or cognitive problems might be clouding the patient's judgment?

As I examine the chart of Ms. Smith I begin to think of what I would do if I were in her shoes, so to speak, as I consider myself a reasonably reasonable person. And, in this case, I would not hesitate to start on IV antibiotics post-haste. But if they wanted to slice open my ankle to let out the steam, I may have to think twice about that. The chart tells me a few important things: no known psychiatric history, fairly standard medical problems of high blood pressure, high cholesterol, history of gallstones, non-smoker, not a drinker.

I approach Ms. Smith, wearing a hospital gown, lying quietly on a hospital bed, walled off from the rest of the ER by curtains only. She looks about her age, thin but reasonably groomed. Her face displays a mask of fretfulness.

"Good morning, Ms. Smith, my name is Dr. Linde. I am a psychiatrist who works in the ER. Your doctor asked me to check in with you."

"Good morning, doctor," she says, managing a weak smile.

"How does your leg feel."

"My leg? What do you mean?"

"Well, Dr. Jones tells me you have a pretty serious infection in both of your legs."

"No, I doubt that. I'm fine."

I lift up the blanket to examine her legs. It looks just as bad as Dr. Jones had described it. I resist the temptation, common to all physicians, to press on her shin to assess the amount of swelling and tenderness, even though it might help break through Ms. Smith's seeming denial of illness.

"What did Dr. Jones explain to you about your leg?"

"I don't know."

"What did she say about the tests she'd like to run and what might happen if we don't treat the infection in your leg."

"I'm not sure."

I was pretty sure Dr. Jones had indeed explained these things to Ms. Smith, but for good measure I told the patient again.

"My understanding is that your legs are badly infected and you're at risk of developing blood poisoning or maybe even losing your foot if the infection isn't treated very soon. The infection could actually kill you. She wanted to draw some blood from you, start an intravenous line, and begin to give you antibiotics. The risks of doing those things is small. We, of course, would want to avoid an allergic reaction to the antibiotic. Dr. Jones also wanted a surgeon to examine your leg, not to do surgery yet but just to be ready in case the infection gets worse."

Ms. Smith truly seems to follow the conversation, quietly listening and mostly looking me in the eye as I speak. Her hands begin to tremble, however.

So I think, given her age, maybe she has dementia or perhaps an acute confusional state, though the history and her behavior do not point to acute confusion or even dementia for that matter. I perform a bedside cognitive screening exam, on which she does remarkably well, scoring 28/30 points. I proceed to screen for paranoia, hallucinations, mania, and depression. As we talk, I soon discover that she is afraid of having her foot amputated.

"My mother was a diabetic and when she was my age, they cut off her foot. I was her main support then. Since I had never married or had children I could take care of her. She died soon after."

Ah-ha, I thought, a symptom model. My psych C-L mentor had taught me about this phenomenon and showed me its importance in the assessment of illness behavior. So, not finding much else psychiatrically, I follow up on her statement.

"That must have been very difficult for you."

"Oh, doctor, you just can't imagine. Her amputation stump kept getting infected, in and out of the hospital. The prosthesis never fit right. She was always in pain. When she died of an insulin reaction, it was almost a blessing in disguise. I never want to suffer like that."

Her statement represents a fountain of clarity. "I definitely understand what you're saying," I say. "It sounds like watching your mother suffer so much really affected you."

"Yes, doctor."

"I'm certain that Dr. Jones would like to prevent any complications and feels that the sooner treatment gets started the better you're going to do. Delaying treatment actually increases the risk of a bad outcome in this situation, Ms. Smith."

"I see," she says, pausing, as I remain silent. "Let me think about it."

"Fair enough," I say. "Dr. Jones will come back to talk to you very soon."

I walk away, thinking that anxiety and unresolved grief are clouding Ms. Smith's ability to make a reasoned judgment regarding her medical treatment. But is it enough to tie her down, draw her blood, start an IV, and give her antibiotics against her will?

I find Dr. Jones in the ER's hubbub.

"How'd it go?" she asks.

"Pretty well. Her thinking is pretty clear. She's just afraid. Her mother was a diabetic who underwent a BKA and died soon after and the memory has her anxious. I tried to explain to her that we are trying hard to prevent anything like that from happening."

"Right, Paul, true enough."

"I have a suspicion that she'll actually let you guys draw blood and start IV antibiotics though officially she told me that she'll 'think about it.'" 

"Thanks, Paul."

"Call me back if you have to."

Turned out that Ms. Smith did allow her blood to be drawn. Her white blood cell count was elevated. Blood cultures revealed no systemic infection of her blood. She was admitted to the hospital, responded robustly to the first rounds of IV antibiotics and was able to go home, ambulating with minimal assistance, with home health care, in five days.

Thankfully, these situations often do resolve themselves, but not usually without letting "the process" play out and the performance of "due diligence" on the parts of multiple players, including the consultation-liaison psychiatrist.

About the Author

Paul Linde, M.D.

Paul R. Linde, M.D., is a San Francisco-based author and clinical professor of psychiatry at the UCSF School of Medicine.

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