An Introduction to Psychiatry An Introduction to Psychiatry Consultation Liaison ServiceConsultation Liaison Service

Bikash Sharma, MDBikash Sharma, MD

PGY: IIIPGY: III

06/ 21/ 201106/ 21/ 2011

Learning ObjectivesLearning Objectives Role of Consultation Liaison (CL) in Inpatient Role of Consultation Liaison (CL) in Inpatient

Hospital setting/ Hospital setting/ (Emergency Room)(Emergency Room) - Consultation Psychiatrist as effective physician- Consultation Psychiatrist as effective physician - The art of Psychiatric consultation- The art of Psychiatric consultation

Diversities of cases encountered in CL serviceDiversities of cases encountered in CL service

Informed Consent Informed Consent Capacity and CompetencyCapacity and Competency Capacity evaluationCapacity evaluation

Consultation Psychiatrist as Consultation Psychiatrist as effective physicianeffective physician

The essence of effective consultation in any The essence of effective consultation in any medical specialty lies in the expert knowledge medical specialty lies in the expert knowledge and skill that the invited consultant brings to the and skill that the invited consultant brings to the bedside. bedside.

If the process is to work, both the consultee and If the process is to work, both the consultee and the consultant must believe this.the consultant must believe this.

The alternative is at best a waste of time and, at The alternative is at best a waste of time and, at worst, a fraud perpetrated on the patient in worst, a fraud perpetrated on the patient in which the best of intentions accomplish nothingwhich the best of intentions accomplish nothing

Kontos N et al 2003Kontos N et al 2003

Art of psychiatric consultationArt of psychiatric consultation

Clinical ApproachClinical ApproachEnvironmental influencesEnvironmental influencesStyle of interactionStyle of interactionUse of languageUse of language

Clinical ApproachClinical ApproachDo:Do:

Think Think PhysiologicallyPhysiologicallyExistentially Existentially AvoidAvoidDistortion of truthDistortion of truthAn Ulterior motivesAn Ulterior motivesIllicit activityIllicit activityImmoral activityImmoral activity

George B Murray, S.J, M.DGeorge B Murray, S.J, M.D

Do Not Do:Do Not Do:

Do not take lowDo not take lowDo not tie your self esteem to the team’s Do not tie your self esteem to the team’s

adoption of your recommendationsadoption of your recommendationsDo not feel the need to make a diagnosis Do not feel the need to make a diagnosis

on day oneon day oneDo not say everything you have to say one Do not say everything you have to say one

day one day one Do not practice checklist psychiatryDo not practice checklist psychiatryDo not predict the futureDo not predict the future

Consultative ProcessConsultative Process

Speak with the referring physicianSpeak with the referring physician Review current and past recordsReview current and past records Review medicationsReview medications Gather collateral dataGather collateral data Examine the patientExamine the patient Formulate diagnosis and recommendationsFormulate diagnosis and recommendations Write a noteWrite a note Speak with the referring physicianSpeak with the referring physician

Role PlayRole Play Specific reason for consultSpecific reason for consult Triage Triage Mental statusMental status Informed consent including patient’s willingness/ Informed consent including patient’s willingness/

awareness to talk to psychiatristawareness to talk to psychiatrist Detailed Past/ Present medical/ psychiatric Detailed Past/ Present medical/ psychiatric

informationinformation Collateral informationCollateral information Recommendation to the primary team directlyRecommendation to the primary team directly Follow upFollow up

Differential DiagnosisDifferential Diagnosis

MedicalMedical PsychiatricPsychiatric presentation of presentation of medical conditionsmedical conditions PsychologicalPsychological reactions to reactions to medical conditionsmedical conditions PsychiatricPsychiatric complications of complications of medical conditionsmedical conditions

PsychiatricPsychiatric Medical presentation of psychiatric conditionsMedical presentation of psychiatric conditions Co morbid medical and psychiatric conditionsCo morbid medical and psychiatric conditions Medical complications of psychiatric conditionsMedical complications of psychiatric conditions

Informed consentInformed consent

11. Salgo Vs. Leland Stanford Junior . Salgo Vs. Leland Stanford Junior University Board of Trustee (1957)- University Board of Trustee (1957)- Informed ConsentInformed Consent

22. Natanson Vs. Kline ( 1960)- Professional . Natanson Vs. Kline ( 1960)- Professional StandardStandard

33. Canterbury Vs. Spence- WDC (1970) & . Canterbury Vs. Spence- WDC (1970) & Cobbs Vs. Grant- CA ( 1970)- Patient Cobbs Vs. Grant- CA ( 1970)- Patient Orientated ApproachOrientated Approach

33 Elements in treatment decision Elements in treatment decision making, ie:Informed Consentmaking, ie:Informed Consent

““DisclosureDisclosure of Information within a context of Information within a context that allows that allows voluntary choicevoluntary choice made by a made by a patient who is patient who is competentcompetent to decide” to decide”

Adequate information > Mental Capacity> Adequate information > Mental Capacity> Informed ConsentInformed Consent

Valid Informed ConsentValid Informed Consent

Permission voluntary given by a competent person Permission voluntary given by a competent person without any elements of force, deceit, coercion without any elements of force, deceit, coercion after explanation and disclosure of after explanation and disclosure of

1.1. Purpose and details of procedure or treatmentPurpose and details of procedure or treatment

2.2. Risks, Benefits and available alternative Risks, Benefits and available alternative treatment/streatment/s

3.3. The right to withdrawal consent verbally or in The right to withdrawal consent verbally or in written forms at anytimewritten forms at anytime

Exceptions Exceptions

Life threatening situationLife threatening situationPatient who waive their rights to disclose Patient who waive their rights to disclose

and consent (do not want to be informed)and consent (do not want to be informed) Instances where “ disclosure’ may be Instances where “ disclosure’ may be

harmful to the patient “ Therapeutic harmful to the patient “ Therapeutic privileges” privileges”

Capacity vs. CompetencyCapacity vs. Competency

ClinicalClinical vs. vs. LegalLegal term that denotes the ability to term that denotes the ability to make rational and reasonably well informed make rational and reasonably well informed decisions by a particular patient (vs. person) in decisions by a particular patient (vs. person) in their treatment and/ or life decision/stheir treatment and/ or life decision/s

Capacity is a Capacity is a clinicalclinical determination that determination that addresses the integrity of addresses the integrity of mental functions.  mental functions. 

Competency is a Competency is a legallegal determination that determination that addresses societal interest in restricting a addresses societal interest in restricting a person’s right to make decisions or do acts person’s right to make decisions or do acts because of incapacity. because of incapacity.

Case Scenario Case Scenario Primary clinician simultaneously assess comprehension of a patient Primary clinician simultaneously assess comprehension of a patient

to what has been discussed about an illness, workups, procedures to what has been discussed about an illness, workups, procedures If there is a concern that patient does not seem to understand If there is a concern that patient does not seem to understand

contents of discussion to a reasonable degreecontents of discussion to a reasonable degree Capacity to informed consent?Capacity to informed consent? CL consult for capacity to make CL consult for capacity to make “ particular”“ particular” decision decision If Primary team and CL both agree that a patient lacks minimal If Primary team and CL both agree that a patient lacks minimal

capacity to consent, then patient is considered capacity to consent, then patient is considered “incapacitated”“incapacitated” to to make decision in that make decision in that “ particular’“ particular’ area area

Alternate decision maker sought out (Alternate decision maker sought out (If not emergency:If not emergency: Health care Health care Proxy Vs. Health care Surrogate/ Living will and advanced Proxy Vs. Health care Surrogate/ Living will and advanced directives. directives. If emergency: If emergency: Emergency Temporary Guardian (ETG) Emergency Temporary Guardian (ETG) until the court determine that pt being incompetent; then a “ legal until the court determine that pt being incompetent; then a “ legal guardian” is designated who takes decision for the patient in the guardian” is designated who takes decision for the patient in the area area specified specified by the court.)by the court.)

QuestionsQuestions If a patient agrees with a procedure or treatment If a patient agrees with a procedure or treatment

recommended by clinician, then the question of capacity recommended by clinician, then the question of capacity is null, and patient is considered capacitated?is null, and patient is considered capacitated?

If a patient disagrees with a procedure or treatment If a patient disagrees with a procedure or treatment recommended by clinician, then the question of capacity recommended by clinician, then the question of capacity arises, and patient is considered incapacitated?arises, and patient is considered incapacitated?

If a patient is incapacitated for treatment of HIV (medical If a patient is incapacitated for treatment of HIV (medical decision) , then patient is incapacitated for consenting to decision) , then patient is incapacitated for consenting to other treatments ( other major life decision/s)?other treatments ( other major life decision/s)?

What is threshold for Capacity?What is threshold for Capacity?

STEPS IN DETERMINING A CAPACITY TO GIVE STEPS IN DETERMINING A CAPACITY TO GIVE INFORMED CONSENT TO HIS/ HER TREATMENT PLANINFORMED CONSENT TO HIS/ HER TREATMENT PLAN

I. Mental Capacity AssessmentI. Mental Capacity Assessment

II. Self disclosure II. Self disclosure

Being mentally ill doesn’t in itself imply a Being mentally ill doesn’t in itself imply a loss of capacity or competency.loss of capacity or competency.

Having Capacity or being Competent until Having Capacity or being Competent until proven otherwise.proven otherwise.

I. Capacity AssessmentI. Capacity Assessment

To have capacity to consent to “treatment”, 4 criteria To have capacity to consent to “treatment”, 4 criteria must be satisfied in a patient: must be satisfied in a patient:

1.1. To understand relevant information about the PROPOSED treatment/ To understand relevant information about the PROPOSED treatment/ treatment OPTIONS/ NO treatmenttreatment OPTIONS/ NO treatment

2.2. Able to communicate a choice consistentlyAble to communicate a choice consistently3.3. To appreciate own clinical situation (To appreciate own clinical situation (insightinsight) with regard to the proposed ) with regard to the proposed

treatment (if a patient is in denial of illness, s/he will not be considered treatment (if a patient is in denial of illness, s/he will not be considered competent)competent)

4.4. To rationally manipulate (reasonable; sensible; sound To rationally manipulate (reasonable; sensible; sound judgment) judgment) provided information/sprovided information/s

Process of Periodical Reassessment and DocumentationProcess of Periodical Reassessment and Documentation

Steps in Mental Capacity Steps in Mental Capacity AssessmentAssessment

A. A. General perspective or specific (Psychiatric hospitalization, ECT)General perspective or specific (Psychiatric hospitalization, ECT) Find out the best language of communicationFind out the best language of communication Determine if patient has adequate information on which to base a decisionDetermine if patient has adequate information on which to base a decision MMSE:MMSE: attention, concentration, memory attention, concentration, memory Inform the patient about Inform the patient about the nature of the disorderthe nature of the disorder, AND , AND the risk and benefit of the the risk and benefit of the

PROPOSED treatment, and of ALTERNATIVE treatments or of NO treatmentPROPOSED treatment, and of ALTERNATIVE treatments or of NO treatmentB.B. Repeat information number of times and in different ways.Repeat information number of times and in different ways. Let the patient paraphrase or restate the understanding.Let the patient paraphrase or restate the understanding. Evaluate nature of questions that patient asks regarding treatment planEvaluate nature of questions that patient asks regarding treatment plan Periodical Reassessment of capacity ( if any change in clinical conditions or, Periodical Reassessment of capacity ( if any change in clinical conditions or,

mental status such as in delirium or any modifications in treatment plan)mental status such as in delirium or any modifications in treatment plan)C.C. If patient has “severe deficit” in understanding information-If patient has “severe deficit” in understanding information- No Capacity to make No Capacity to make

informed consent or make decisioninformed consent or make decision Arrange a process for “ a substitute Arrange a process for “ a substitute decision maker”decision maker”

II. Self disclosureII. Self disclosure

A. Consider the fact that patients will not disclose their thoughts A. Consider the fact that patients will not disclose their thoughts and emotionsand emotions

Stigma towards mental illnessStigma towards mental illness Fear of legal consequencesFear of legal consequences Fear of hospitalization or prolongation of hospitalization or limitation Fear of hospitalization or prolongation of hospitalization or limitation

of privilegesof privileges Psychiatrist as Omniscient:Psychiatrist as Omniscient:- can reliably predict the most unpredictable human behavior- can reliably predict the most unpredictable human behavior- can read mind- can read mind- “Lie detector”- “Lie detector”

Common misconceptions towards skills of mental health Common misconceptions towards skills of mental health professionals: an uncertain treatment outcomeprofessionals: an uncertain treatment outcome

II. Self disclosureII. Self disclosure

B. Acknowledge the uncertainty of treatmentB. Acknowledge the uncertainty of treatment Explain DIRECTLY to the patient that the clinician MUST rely on Explain DIRECTLY to the patient that the clinician MUST rely on

patient’s self discloser in order to be of most help.patient’s self discloser in order to be of most help. Explain and ask explicitly to the patient the risk in withholding and Explain and ask explicitly to the patient the risk in withholding and

benefit in providing information benefit in providing information For those who For those who do not understanddo not understand the importance of reporting the importance of reporting

potentially dangerous thoughts or emotions or potentially dangerous thoughts or emotions or unable to reportunable to report for for whatever reason (including denial of illness) will require more whatever reason (including denial of illness) will require more conservative management.conservative management.

For those who sufficiently understand the significance of reporting For those who sufficiently understand the significance of reporting their dangerous thoughts or emotions, DOCUMENT it.( if patient their dangerous thoughts or emotions, DOCUMENT it.( if patient later elect not to report and consequently engage in self- injury, this later elect not to report and consequently engage in self- injury, this DOCUMENTATION will reveal that the patient understood the risk DOCUMENTATION will reveal that the patient understood the risk of withholding information and that the decision not to seek help was of withholding information and that the decision not to seek help was a deliberate (VOLUNTARY) and RATIONAL choice (Gutheil TG et a deliberate (VOLUNTARY) and RATIONAL choice (Gutheil TG et al. Bulletin of American Academy of Psychiatry and the Law, 1986). al. Bulletin of American Academy of Psychiatry and the Law, 1986).

The fundamental issue is whether the The fundamental issue is whether the person can be held accountable for the person can be held accountable for the consequences of his or her decisions and consequences of his or her decisions and actions. actions.

Physician liability for suicidal Physician liability for suicidal patientpatient

The psychiatrist’s goal is to identify those The psychiatrist’s goal is to identify those individual who can “follow an agreed upon individual who can “follow an agreed upon treatment plan treatment plan as well asas well as need for reporting any need for reporting any potentially dangerous thoughts or feelings potentially dangerous thoughts or feelings BUTBUT then later may choose not to as a result of being then later may choose not to as a result of being too sick, depressed, hopeless, psychotic.”too sick, depressed, hopeless, psychotic.”

““Stronger the therapist’s documented grounds Stronger the therapist’s documented grounds for finding the patient competent and thus able for finding the patient competent and thus able to act TRULY voluntarily, the more remote the to act TRULY voluntarily, the more remote the prospect of malpractice liability is likely to be”prospect of malpractice liability is likely to be” (Law at Massachusetts Mental Health)(Law at Massachusetts Mental Health)

Suicide Assessment:Suicide Assessment:

To predict the most unpredictable and the To predict the most unpredictable and the most rear event of another individual.most rear event of another individual.

Suicide  Assessment  Suicide  Assessment  Dr.  BarnesDr.  BarnesPsychiatric emergencies Psychiatric emergencies Dr. BlandDr. BlandManagement of Acute AgitationManagement of Acute Agitation Dr.  KhurshidDr.  Khurshid Involuntary Commitment Involuntary Commitment Dr. Malik Dr. Malik