Friday, July 26, 2013

Guest Blogger Simple Citizen on The Suicidal Patient's Right to Have Advance Directives Honored

Simple Citizen is a psychiatrist reader with his own blog (see our sidebar).  This started as a comment, but I asked to use it as a stand-alone post.  Dr. Citizen writes:

We have the right to die, but not the right to commit suicide.

This makes my life in Consult Psychiatry extremely difficult, especially when someone has an Advance Directive that states "Do-Not-Resusciate" and then they try to kill themselves.

They arrive at the hospital in critical condition, the medical team knows the need to be intubated and they are likely going to go into cardiac arrest. Should they intubate them and save them because suicide is illegal, and the person may want to live when they are not in crisis? Or do the doctor's let the patient die because of the patient's pre-written wishes?

Worse yet - what if the person didn't have an advance directive, but when they are crashing in the hospital, they tell the whole medical team that they refuse CPR and intubation. Does a person who just attempted suicide have the capacity to make that decision?

More of my thoughts here if you're interested:


So here's my question: okay, it's one thing if someone checks into a hotel room, makes a serious attempt, notifies no one, has an Advance Directive in their hand and a DNR order tattoo'd on their forehead, but oops, the maid finds them.   That's it's own touchy issue -- unless you're their wife or mother or son, in which case I don't think it's a question at all.  But what do we do about the patient who overdoses, then emerges from the bathroom to tell their significant other "I just took all my pills".  Or the person who makes an attempt then dials 911 or goes to the ER.  How do you stand there and let someone die because they have a piece of paper saying they don't want CPR or intubation?  Is it really reasonable to have this type of attempt and announce it?  Isn't there an element of cruelty to it?  So many people attempt suicide and wake up glad to be alive.

I'm going to add that I don't believe Advance Directives made by people without psychiatric disorders are binding if the patient does not have a terminal illness.  A healthy  person can't go into a routine appendectomy or tonsillectomy and say "if something goes wrong, you can't even attempt to resuscitate me."  No surgeon or anesthesiologist would ever accept that malpractice risk. --"I'm so sorry Mr. Smith, buy your 20 year old son had a tension pneumothorax during the procedure, and we could have intubated him and put in a chest tube, and he'd have spent a couple of the days in the ICU then made a full recovery, but he said no tubes/no intubation."  Advance Directives are meant for situations where someone has a terminal condition -- cancer or Alzheimer's Disease, or AIDS.  And what would we do about children?  Would we allow a parent to make a healthy child DNR in the event of treatable illness?


jesse said...
This comment has been removed by the author.
jesse said...

I'm very glad SC's comment ended up as a post, because it's quite clear that he is anything but simple and put his finger right on some of the difficulties we face in these situations. In answer to your question, Dinah, the person who tells others or goes to the ER is showing his ambivalence. He wants the other person to react.

One of the most valuable consequences of these examples is that they lead us to examine our premises. Uncertainty and ambivalence abound in these situations: ambivalence on the part of the acting person and uncertainty as to what is best to do on the part of those around him.

PsychPractice said...

First off, I don't envy Simple Citizen for being in the position of making this call. That's an awful place to be.
I've never been comfortable with the way advance directives are set up. We ask the patient, what do you or don't you want done if you are in a life-threatening medical situation? Do you want to be intubated, resuscitated, placed on a ventilator? These are the wrong questions. Unless you work in a hospital, you probably don't have a good grasp of the rib-cracking reality of a code.
The right question is, "What state do you need to be in for life not to be worth living anymore?"
The person who overdoses in a hotel room without telling anyone, and is accidentally found by the maid, is saying that he had reached the point where life wasn't worth living anymore. Whether he could have been helped to feel better is subject to debate, but his message is clear.
I agree with Jesse that, "...the person who tells others or goes to the ER is showing his ambivalence." But it's not ambivalence about having a tube down his throat.
And to take it one step further, Jesse also writes, "He wants the other person to react." I would say, not just react. Not just recognize a cry for help. He wants the ER staff to make the decision for him, to either participate in his suicide, or to save him "against his will".
I'm glad I don't work in an ER.

jesse said...

PsychPractice writes "He wants the ER staff to make the decision for him." This is a profound observation. Sometimes we can become so upset, so frightened, so confused by choices in front of us that we want someone else to make the decision for us, whether it be a relatively trivial matter like an item of clothing or a life changing one.

In some of these situations we still make the final decision, to buy this dress or that one, for example. In others the persons we go to may have their own constraints: the hospital physician acts to save lives, not to assist a suicide. So when a person comes to the ER he is putting himself in the hands of people who have their own moral and legal imperatives.

Steven Reidbord MD said...

Consider a couple of additional examples to help clarify the issues. What if a patient took an overdose or cut their wrists and then refused treatment, i.e., immediate first-aid, in the ER? We would consider the refusal part of the attempt itself, and would not honor it. This happens fairly frequently in real life and isn't particularly controversial if you ask first responders or ER staff. EMTs and paramedics say there's "implied consent" to treatment when they arrive, no matter what the patient happens to be yelling or screaming at the time.

Conversely, consider the person (patient or not) slowly killing himself with self-neglect, undue risk-taking, unhealthy habits (eg, smoking) or the like. People have a right to do this, and they don't even need a signed paper to be left alone.

Advance directives arose to document consent, or the withholding of consent, in situations when it cannot be voiced directly. They do not confer any additional rights or privileges than a patient would have anyway, were he lucid, competent, and able to express his wishes directly. Thus, an advance directive is immaterial in situations where obtaining consent isn't done anyway, as when the EMT encounters the overdose victim. Moreover, doctors and medical facilities aren't legally obliged to provide "futile" interventions or to practice in ways they consider morally reprehensible, no matter what an advance directive says. In these latter cases, a good-faith effort should be made to transfer the patient to care that accords with his wishes. However, depending on the extremity of those wishes, this isn't always possible.

The psychological issues — refusing rescue in settings designed for just that purpose, expressing ambivalence over agency and one's self-destructive impulses — have already been mentioned above, and are much more interesting and challenging to me than the "what do you do?" question.

Simple Citizen said...

The hard part to me is not always the patient, but the other physicians. They often treat a DNR or the patients wishes as the ultimate and only word. They seem to misunderstand that capacity to make decisions is domain specific - meaning that while the patient may have the capacity to make thousands of other decisions, they lack the capacity on that day to make THAT decision. Their "death wish" for no treatment after a suicide attempt should not be honored.

It seems straightforward, but when it's Saturday night at 11 pm, no one wants to "ignore" a DNR order, nor are they willing to call the ethics committee or hospital administrators.

roblindeman said...

Tough cases make bad law, and good ethics require good facts.

There are are too many squishy "what ifs" in this scenario for any general principles to emerge.

There IS, however, one general principle that I wish would ride over all these scenarios: That is, the impermissibility of COERCION

styles said...

A healthy person can't go into a routine appendectomy or tonsillectomy and say "if something goes wrong, you can't even attempt to resuscitate me."

...I thought you could get a DNR no matter what. I posted on this on the Emancipated Patient article.

"People have brought up the Jehova's Witnesses and their right to refuse blood transfusions. Someone in my own family actually died for that reason. She was my great grandmother. She was also a Lutheran. But he her daughter converted to the Jehovas Witnesses faith. Great grandma had a fall and needed a blood transfusion. Her daughter was the nearest relative. The hospital got in contact with her so she could consent to a blood transfusion for her incapacitated mother. She refused. Remember that the MOTHER was not a Jehovas Witness. Only the daughter was. Great grandma died and my my grandfather literally did not talk to his sister for like twenty years after he found out that she killed their own mother by refusing to allow a blood transfusion. I don't know if the doctors were shedding any tears."

Doesn't this apply even to their kids...unless I'm missing something, they can refuse a life saving treatment for people who are not terminally ill. What about the Amish? Those people don't even believe in electricity, and their kids get plenty of health problems as a result. I remember watching Breaking Amish where the 19 year old Amish girl has no teeth. She informs the viewers that this is actually pretty typical. Many young Amish have dentures. They have some guy, totally untrained or licensed in dentistry, who comes in and pulls out all the teeth with some kind of device and gives you ill fitting dentures.

At least when she left the Amish, a kind dentist made her a real set of dentures that didn't hurt and fit well. Couldn't she have potentially died from a gum infection? But they don't believe in modern

I'm just saying, we let people do all kinds of stuff that is horrible for their health. I think if we let Jehovas Witnesses block blood transfusions in people not terminally ill, then this should apply to other areas where life saving treatment is denied.

styles said...

I have no idea if this is legal, but I just went on wiki and under the JW and blod transfusion topic, the American Academy of Pediatrics reccomends disregarding what the JW parents want (no blood transfusion) if the child is in imminent danger.

Guess we do have some loopholes. Still, adults have more rights.

Je Suis said...

This statement by Simple Citizen -

"They seem to misunderstand that capacity to make decisions is domain specific - meaning that while the patient may have the capacity to make thousands of other decisions, they lack the capacity on that day to make THAT decision." -

may well be the most absurd, self-serving piece of "reasoning" I've ever come across. What is really being said is that an individual who is perfectly capable of making "thousands of other decisions" both rationally and competently, who by default is alert and oriented, becomes incompetent the moment they make a decision that is unpopular. One that the author does not agree with. How...convenient. Not to mention somewhat Orwellian.

Where does this end? How many decisions can we negate because someone doesn't agree with them? Will this work in a court of law? Something like "your honor, I know that he shot and killed his wife, but since I don't like his decision to kill her, I find him to have been incompetent to make the decision to kill her at that time. Yes, I realize he planned it, and was capable of making the complex decisions leading up to the murder, but the murder itself doesn't sit well with me, so in my professional opinion, he was incapable of making that decision rationally at that time. Remember that this is domain specific, and he is completely capable otherwise, just not while he was deciding on murder".

Will that get him off by reason of insanity? More importantly, would any psychiatrist be willing to testify along those lines? if not, why not? it falls perfectly in line with the stated assertion that one can be incompetent to make a single decision while remaining perfectly capable otherwise.

Steven Reidbord MD said...

@Je Suis: I'm sorry if it upsets you, but Simple Citizen is spot on, both in the original post and in the comment that irked you. The American legal system, as well as academic ethicists, recognize that the capacity to make one type of decision, e.g., to sign a contract, is independent of the capacity to make other types of decisions, e.g., to write a legal will. In health care settings, the capacity to consent to routine medications may be preserved while the capacity to make harder and weightier decisions about surgery is not. Likewise, a suicidal patient usually retains the capacity to make medical decisions even while his wish to die is not honored. Simple Citizen was right: Many physicians (and others) fail to understand that decision-making capacity is domain-specific. You could look at this as cherry picking, i.e., respecting only decisions one agrees with, but actually the aim is to preserve as much autonomy as possible in those who lack a degree of it.

Anonymous said...

"The American legal system, as well as academic ethicists, recognize that the capacity to make one type of decision, e.g., to sign a contract, is independent of the capacity to make other types of decisions, e.g., to write a legal will."

Though I can't speak for academic ethicists, as a practicing member of the American legal system for 30+ years, I have never heard of the notion that decisionmaking capacity is domain-specific. Can you cite to some legal precident or academic article? Or is this something you just decided (assuming you have decisionmaking capacity in this domain)?

Anonymous said...

Ooops. Should be "precedent."

Je Suis said...

@ Steven Reidbord MD

It isn't that it upsets me so much; it's that the whole domain-specific decision making capacity argument is specious reasoning at best, an intellectual dishonesty masquerading as truth. Either one is competent, or one is not. Anything else is, as you put it,
"cherry-picking" the decisions one agrees with, and discarding the decisions one does not.

A perfect example of this is simple: the fact that, in a suicidal individuals case (at least for someone who has been suicidal for some time before acting on the feeling) the decision to commit suicide is one in which it's claimed said person lacks the capacity to make. However, the decision to not commit suicide, which has been made numerous times prior to that point, is within their capacity? Why? It's the same decision, but when decided the socially acceptable way (to not commit suicide) they are considered
to be competent to make that decision, but when decided the socially unacceptable way (to commit suicide) they become incompetent? How can this be? No, the more obvious answer is that it's not about competency at all, but merely about social acceptability. A punishing of those who make decisions that are not agreeable. A "do as I say, or else" mentality. So much for preserving autonomy: cherry-picking and acknowledging only the decisions one agrees with while discarding the decisions one does not does not preserve autonomy; it destroys it most efficiently.

I won't comment on domain-specific decision-making competency from a legal point of view, as the anonymous poster following your post did so already; however, I would also like to hear about the legal precedents or even academic articles covering the topic. Please enlighten us further.

jesse said...

A number of years ago a patient, who was dying and having periods of confusion, wanted to write a certain person out of his will. I was asked to sign a statement regarding his capacity to do that, and was informed by a prominent estates attorney that the standard used to judge whether a person had the capacity to make such a decision was a low bar, virtually at the level of whether he understood what he was doing. Other types of decisions might require a higher standard of understanding.

As Dr. Reidbord used the term “capacity,” I looked it up in a legal dictionary. Capacity indeed varies with domain. For instance, an eighteen year old has the legal capacity to vote, but not buy alcohol here in Maryland. A thirty year old does not have the legal capacity to serve as president. One might legally be able to vote in Maryland where he is a resident, but not in Delaware where he is not. In general, it is much easier for someone to “opt-in” to a contract than to back out of it: It can be presumed that a given person might have the ability or “capacity” to enter into a contract, while for that person to back out of the contract would require much more complex demonstrations of mental functioning and understanding.

A person may be considered to have the capacity to consent to life-saving care (a very loose demonstration of understanding) while at the same time being deemed as neither having the capacity nor authority to refuse it. All of us physicians are saying here that there are constraints on and demands of the hospital staff which are not not easily overridden by a sudden verbal statement by the patient. This is just a fact, not necessarily our wish.

The situation in the ER involving involuntary admission of a suicidal patient is different. It is not that the patient is considered to have capacity to assent but no capacity to refuse admission. The criteria for allowing the patient to sign a “voluntary” might be very loose, while if he refuses to do so there are other constraints and requirements that determine what the staff can or must do. I think this is what Simple Citizen and Dr. Reidbord are saying.

Steven Reidbord MD said...

@anon: Domain specificity of decision-making capacity is well established in the literature of medicine and medical ethics. E.g.: [see about halfway through this PowerPoint on domain specificity]

For a philosophical discussion (esp section 3):

@Je Suis: "Either one is competent, or one is not." No, please see the above papers. Your example of the person who has long contemplated suicide illustrates, as you claim, unequal application of competency concerns. Our society (and we personally, in everyday life) scrutinize more carefully unusual or potentially regrettable decisions. Your computer asks twice if you really want to delete a file, but it accepts a "save" command without confirmation. Here in California, a suicidal person can be held involuntarily for assessment and safekeeping for up to 1 month (with judicial review); after that the law says they must be released. Since many people feel impulsively suicidal and later change their minds, a temporary presumption of incapacity saves many from taking an action they would later regret. Yes, it's state paternalism, but no moreso than laws requiring a waiting period before buying a handgun. It's one of those prices we pay to live with each other in society.

@jesse: Yep.

Steven Reidbord MD said...

I couldn't find it online just now, but my favorite paper on assessing decision-making capacity:

Appelbaum PS, Assessment of Patients' Competence to Consent to Treatment, N Engl J Med 2007;357:1834-40.

Well worth reading, if this topic is important to you.

Anonymous said...

I see a psychiatrist who I very much like, but I do share some of the same concerns that Je Suis expressed. In fact, Simple Citizen's statement is what scares me the most about being a psychiatric patient.

Many years ago I was taken to an ER against my will. Once there, they decided I needed to be admitted and I was told that if I did not sign the informed consent document agreeing to be hospitalized (and in the informed consent document I also had to agree to be photographed, agree to risks, agree to people in training working with me, agree to accept financial responsibility, etc) then they would hospitalize me anyway and if they did it their way it would be harder for me to get out. I very clearly and explicitly continued to state that I did not want to be hospitalized and that I was only signing because they were threatening me. That's not informed consent. You cannot have it both ways and say that patients only have capacity to say yes. It would have made more sense if they had just treated me as an involuntary patient rather than pretending that I had agreed to what I very clearly and explicitly verbalized I did not agree to. So, on paper I was a "voluntary" patient, except for the part about me being there against my will.

We don't do that to patients with dementia, by the way. I know, because I worked with those patients for many years. If they said no to treatment and they lacked capacity to make that decision, no one threatened or coerced them into signing anything. If they didn't agree or didn't understand, then they didn't sign. Period.

If I was so ill that I couldn't say no to treatment, then they had no business having me sign an informed consent. That's not right. Forget capacity for a minute, let's look at the basic tenets of the informed consent process. Threatening or coercing people to sign an ICD, however well intentioned, is not informed consent. It's just not. I do get that it is well intentioned, but well intentioned doesn't make it right.

State your case, and if the patient meets legal criteria for admission (and I probably did) but says no, then treat them as you would any other patient who lacks capacity. I may not like or agree with the law, but a different issue.


Anonymous said...

I meant to say:

I may not like or agree with the laws regarding involuntary hospitalization, but that's a different issue.

Pseudo Kristen

Anonymous said...

So, when you get right down to it, all this discussion about capacity is really a semantic circus, since the patient has no actual ability to decide for themselves. Should that patient make a decision that is not in agreement with the so-called caregivers, then they are simply judged to lack the capacity to make that decision, while at the same time they are urged to make the same decision, so long as it agrees with the intent of the persons urging them into it? Why all this man-behind-the-curtain smokescreen tactics? Why not just plainly state the fact that the patient has no actual say in the matter; rather than telling them that they only have capacity to make decisions if the decision they make is one that is the agreeable one? Is this how the mentally ill are helped - by playing these kind of games with them? I asked this once before, in another thread - just how sadistic does mental health get?

Je Suis said...

@Steven Reidbord MD

"Your example of the person who has long contemplated suicide illustrates, as you claim, unequal application of competency concerns. Our society (and we personally, in everyday life) scrutinize more carefully unusual or potentially regrettable decisions. Your computer asks twice if you really want to delete a file, but it accepts a "save" command without confirmation.

Your example only serves to highlight my point. Yes, we scrutinize regrettable decisions, thus the mention of an individual who has been suicidal for a long time; i.e. someone who has been considering the pros and cons for some time. Repeatedly they decided that no, today is not the day, but they eventually reach the 'right' time and decide to go through with the act. Same decision, and one contemplated numerous times (many more times than say, your computer asking twice to delete a file); yet when they make that one decision, the one that they have spent years pondering, you immediately claim a loss of capacity based solely on the fact that the decision made is not an agreeable one. You're fine with their decision making as long as it agrees with your values, or beliefs, or whatever; but as soon as it doesn't, well, then obviously the individual in question is incapable. This is so sophistic, so inherently self-serving that I have to question whether the best interests of the patient are even
a factor in these affairs. it reminds me of that old saying: when you have a hammer, everything looks like a nail".

Je Suis said...

@ Jesse

Your examples only serve to sum up the problems I have with the capacity argument. A 30 yo cannot be president, a 34 yo cannot be president, but a 35 yo can be. What happens in that year, from 34 to 35? Do we undergo some kind of apotheosis, gaining wisdom to equal Solomon? Sadly, based on past and present examples, it would appear not. Therefore, the capacity to become president at age 35 is somewhat arbitrary, is it not? Similarly, the determination involving one's capacity to make decisions in health-related matters seem to be a bit arbitrary as well. Look at the 18 yo - he can drive (how many
people die in auto accidents each year?), vote, join the military and kill for his country, but not drink? How does that make sense?
The answer is actually easy - because it's convenient. We need young people in the military, or to work, but we don't need people to drink. Convenience. Just like the capacity-making argument -it's just easier to say that someone can't make a decision that we don't want them to make.

As for the contract example - it's apples and oranges. The example you give is one of making a decision, then changing ones mind -
while the discussion is about the ability to make that initial decision.

jesse said...

@Anon: it is not a semantic circus at all. This is a complex issue that Simple Citizen brought up, that there are conflicting pressures that affect the caregivers. Yet you are bringing up an important point: If you are going to make me do it anyway why are you pretending that this is “voluntary?” This is an excellent question. In terms of the hospital, imagine that there were no choice. As soon as the ER staff determined that a person were imminently suicidal they would immediately certify that patient. No offer of a voluntary admission. Would this be preferable and fairer to the patient?

The consequences to anyone of having been involuntarily admitted are quite different from that of a voluntary admission. Beyond how it might impact how the hospital may have to treat the patient, think of how it might affect getting insurance, for example. Or possibly a job, credit, and so on. Would anyone be better off because their record indicated an involuntary admission? So when the staff offers a voluntary, some of the motivation may be to spare the patient the consequences of the involuntary. Consequences which are not imposed by the hospital staff, but by others.

The point of the original post was not involuntary hospitalization but an attempt to explore the complexities of decision making with terminal patients who had signed directives. SC said it succinctly, “We have the right to die but not the right to commit suicide.” To quote Hillel, “the rest is commentary.”

Je Suis said...

@ Jesse

In some states, like Florida, the consequences of being involuntarily admitted vs an voluntary admission are not very different at all. Florida passed a law that mental health patients who are voluntarily admitted are reported to the government in the same manner as involuntarily admitted patients, so that they can go on a list and have at least some of their rights removed. If you voluntarily admit yourself, then it's automatic, while if you refuse, you at least get a court appearance to plead your case. This idea is gaining in popularity - it's ostensibly to keep the guns out of the hands of the dangerous people (this according to Florida's governor, who obviously thinks that all mental health patients are dangerous; so much for reducing stigma..), but the end result is that a mental health patient is always better off refusing to admit themselves so that they at least have a chance with the courts. What I wonder is this: if this idea becomes nationwide, will the staff pressing for voluntary admission then explain the damages caused by agreeing to the admission? That the patient is better off by refusing? Somehow I doubt it. Again, because it's convenient; it's so much easier if the patient agrees. No fuss, no muss.

The most interesting thing about your post is this: " it might affect getting insurance, for example. Or possibly a job, credit, and so on. Would anyone be better off because their record indicated an involuntary admission?" In other words, the suicidal patient, who may have been suffering for years in a life that is unbearable, is forced to live, and live with the added burdens of stigma, loss of rights, financial hardships, loss of work and/or difficulties finding new employment, just to name a few - all while still trying to cope with the issues that brought them to that point in the first place. And you mental health professionals think you are helping? Really?

I've said this before as well - mental health treatment has little to offer; drugs and therapy mainly, and in some cases they are spectacularly unsuccessful. By the time the patient discovers this, it's too late - they are saddled with the consequences that you claim voluntary hospitalization protects them from.

To sum up, any encounter with the mental health professionals is rife with risks - those risks being the additional burdens placed upon the patient once labeled mentally ill. One is better off dealing with their issues in silence, and if it reaches the point of suicide,
then be damn sure to be successful the first time. Because, as has been demonstrated, even someone with an advanced directive, someone who has no mental health issues and made their decisions clearly and concisely, can and will be countermanded with the reasoning that they do not have the capacity to make the decisions affecting their own lives (and deaths), but the complete stranger who sees them in their time of crisis has a better understanding of their issues, and a better right to make those decisions, no matter how it turns out for the patient. Because that professional has something the patient doesn't: that professional never lacks the capacity to make that decision for the patient, the same decision that the professional has decided the patient cannot make; wishes and directives be damned. Huh. I guess doctors are closer to God after all.

Anonymous said...

I understand the post is not about involuntary hospitalization, but it comes up because patients who are so ill that they cannot say no to hospitalization are then asked, in some cases (probably many cases) coerced, and even at times threatened to sign an informed consent for hospitalization. We are too ill to say no, but well enough to say yes. While there may be laws to support this type of cherry picking as it's been called, it still doesn't address the fact that the patient who apparently had capacity to say yes was then treated without a valid informed consent.

If the person responsible for obtaining consent knows that the patient did not consent to the hospitalization (i.e. the patient is verbalizing she doesn't agree with what she's signing, she says she feels threatened to sign, etc) then you do not have informed consent. The informed consent process involves more than a signature on a piece of paper, and if the physician and everyone else in the room knows the patient doesn't agree with what they're signing then it's not voluntary. I understand that coercing and/or threatening patients to get them to sign the informed consent is well meaning, and that part of it may be to try and save patients additional problems that come with being classified as involuntary; however, it still does not change the fact that the person who had capacity to say yes didn't really say yes. So, now you have a person who has capacity to say yes to treatment being treated without informed consent. That's a problem. (In my situation, I don't think changing my classification to voluntary made much difference, because I was first put under an emergency detention so that was already on record. I guess i was an involuntary patient who became voluntary, well sort of voluntary, except not really. It's all so confusing).

Maybe the answer is to have an outside party witness the informed consent process to ensure that the voluntary patients are really voluntary. Since psychiatric patients are classified as a vulnerable population, even greater care should be taken when obtaining consent. Patients have to have the freedom to say no, or you do not have informed consent. You have a signature, and that is all.

While I certainly have a whole host of concerns about inpatient psychiatric care, I don't believe in throwing the baby out with the bathwater. I would much rather see inpatient care improved and patients' rights better protected. Inpatient care caused me a lot of problems, but outpatient care not only improved my life, it's pretty much the reason I'm still here. Medications do help some people. I don't have to deal with all the delusions I use to have; it was not a fun way to have to live. So, I'm grateful. But, still, I want my core values to be respected in an inpatient setting and I have my concerns that they might not be. I don't ever want to be threatened to sign informed consent. That's not consent.


jesse said...

Very well put, P-K. Numbers of people have had bad experiences as you describe, and even if later they are alive when they otherwise might not have been, the experience was hurtful to them. So it is a very valid question to ask how this type of hospitalization can be made better. Dinah is writing a book on this very subject. I'm looking forward to reading what she says.

Simple Citizen said...

I appreciate all the comments and conversation. This topic led me to a lot of research and a publication on the topic.
I just want to clarify or add two things.

Legal definitions are VERY important. Such as:
◦CAPACITY = Clinician’s assessment / decision
◦COMPETENCY = Judge’s assessment /decision

When determining a person's capacity to make a decision they have to meet four criteria:
1) Understanding (they know what’s wrong)
2) Appreciation (they understand the options)
3) Reasoning (they can come to a decision)
4) Choice (they can communicate the decision)

That's the reason their capacity can change so quickly, and can be different for different decisions.

Je Suis said...

◦CAPACITY = Clinician’s assessment / decision

So, to recap - the suicidal patient lacks the capacity to make that decision simply because of the clinician's assessment; and that assessment hinges on four points:

1) Understanding (they know what’s wrong) - understanding is a bit more complex than knowing what's wrong, but lets take a look at that. Wrong for whom? Wrong how? Morally wrong, legally wrong, financially wrong? Is is a religious wrong, like sin? This wrong seems to require a better definition than simply "wrong"; otherwise it's just placard used to justify the clinician's personal feelings. Just who is the final arbiter of this right and wrong, anyway? Is 'wrong' a universally accepted state, or is it a fluid, protean concept?

2) Appreciation (they understand the options) - What if the suicidal individual does understand the options, and decides that suicide is their best option available? Do they lack capacity just because the clinician doesn't agree with them?

3) Reasoning (they can come to a decision) - This one is a puzzle. It would seem that someone who has made a serious attempt has, in fact, made a decision. Does this mean that it has to be a decision that the clinician agrees with?

4) Choice (they can communicate the decision) - It seems as if, having made an attempt, a choice has been made. However, this choice is defined as communication - which is a catch 22 in and of itself, since communicating the choice of suicide will end with the suicidal individual being held against their will for at least 72 hours, while being judged to lack the capacity to make this choice.
A nice bit of byzantine reasoning here.

So, in the end, it comes down to this: one lacks capacity if their
understanding of a vaguely worded wrong doesn't match the clinician's
idea of wrong; if they don't appreciate that their options do not include suicide (even though it is actually an option, generally speaking); if the decision that they come to regarding suicide doesn't match the decision deemed acceptable by the clinician, or if they do not or will not communicate their choice to the clinician. Nice. Got it pretty much sewed up there, either agree with the clinician or you lack capacity. I doubt Machiavelli could have done much better.

Anonymous said...

CAPACITY = Clinician’s assessment / decision

I think the definition illustrates the problem. I would agree with Je Suis in that it seems that physicians tend to over attribute disagreement with the clinician as evidence psychiatric patients lack capacity. When do you ever hear of a psychiatric patient who agrees to sign an an informed consent for psychiatric treatment being denied because they lack capacity?


Anonymous said...

Jesse, I'm looking forward to the book, too.


firma remontowa kraków said...
This comment has been removed by a blog administrator.
styles said...

I am happy that Dr. Citzen was inspired to do more research and get published on this topic. Good for him.

Steven Reidbord MD said...

Simple Citizen's recent comment is correct but a little confusing, as it applies to MEDICAL decisions:

1) Understanding (they know what’s wrong) "I have cancer"
2) Appreciation (they understand the options) "I can choose chemotherapy or comfort care"
3) Reasoning (they can come to a decision) "Chemo may prolong my life, but I prefer to reduce my suffering"
4) Choice (they can communicate the decision) "I want comfort care"

Some of the comments above conflate civil commitment (eg, a suicide hold) and capacity to make medical decisions. Here in California, patients on a hold can still refuse non-emergency psych meds unless an additional "Riese hearing" judge finds them unable to do so, using the 4 capacity criteria above. Commitment laws aren't based on capacity, they're based on the police powers of the state to deprive citizens of liberty in dangerous situations. This sounds ominous, but the original intent was to replace looser "need for treatment" rationales to commit the mentally ill.

One last comment to Je Suis, and I'll let you have the last word if you wish. No matter how rational and long-considered, a suicide plan will never be endorsed by one's psychiatrist. It's not our job to judge whether your life is worth living. It is our job (in part) to put distance between you and your self-destructive impulses. If you fully identify with those impulses, with very rare exceptions we won't even cross paths. You'll simply be dead, like 30k+ other Americans this year. However, if you come to a psychiatric facility (or post on the internet) and argue with me that your suicide plan is rational, I'll take that to mean you have mixed feelings about it — why else would you expend such effort to sway someone you don't even know? — and I will side with the part of you that wants to live. You can count on it.

Anonymous said...

Dr. Reidbord writes, "Some of the comments above conflate civil commitment (eg, a suicide hold) and capacity to make medical decisions."

You may not be talking about me, but I do understand the difference. At one point in time, I was actually involved in the informed consent process of numerous patients, and I intervened if the patient verbalized they did not have a clue what was going on (i.e. they couldn't tell me the name of the treatment or even the type of treatment that they were signing consent for, or they said they didn't know their diagnosis, they said the physician had not talked to them about it, they couldn't keep their eyes open, they had just been medicated with sedating medications, they expressed conflicting thoughts about what they were signing, they had more questions, etc). At that point, I would back out of the room and go find the physician. The informed consent process stopped until those issues were resolved (and they weren't always resolved).

I don't see the same care taken when it comes to consenting psychiatric patients for psychiatric hospitalization. I don't hear of staff stopping the informed consent process of psychiatric patients, it seems as long as the patient will sign the paper that's enough. Interestingly, when this discussion came up, I came across a lot of information on the coercion of psychiatric patients when signing consent for "voluntary" hospitalization. There needs to be a lot more attention given to consenting patients who have already said no, or don't have a clue what they're signing, etc. I can tell you that care is not being taken, hence the research on the topic. If it's a civil commitment, then the patient has due process (in theory, anyway). They don't have due process if they are being coerced or threatened to sign consent for "voluntary" hospitalization. And, if the patient is coerced to sign, they have not consented to anything. Kind of like a coerced confession, they may mean what they're saying or they may just be saying it to get you to stop. Coercion to sign does not equal an agreement. Do it involuntarily if the patient is saying no, so at the least the patient has due process. Don't call it informed consent if it's not.


Simple Citizen said...


I'm glad you brought that up. It scares me how the "power of the legal hold" translates into coerced medical consent, "voluntary" admission, etc...

I've seen many people "Voluntarily" admitted who were told they'd be put on a legal hold if they refused, the staff just wanted to avoid the paperwork.

The point has been made - though people are on legal holds and don't have the right to choose to leave, they still have the right to refuse medications, refuse invasive procedures, lab draws, etc.

ClinkShrink said...

I was trying to publish a comment in the moderation cue but I fumble-fingered and accidentally deleted it instead. So, I'm going to copy and paste it here on behalf of the commenter. My apologies.

Here it is:

Je Suis has left a new comment on your post "Guest Blogger Simple Citizen on The Suicidal Patie...":

@Steven Reidbord MD

I will take that last comment you so graciously offer. in response;

"a suicide plan will never be endorsed by one's psychiatrist'

I never asked for one to be endorsed, simply accepted. Accept the fact that some don't view suicide inn the same light as a psychiatrist does. Stop punishing people who try it and fail - it isn't as easy as it appears, plenty of people who are serious nevertheless end up surviving, especially a first attempt. Stop pretending that there is 'help' for everyone, and that a psychiatrist can help everyone. They can't, and it's a lie. Some, certainly, but not everyone. Yet everyone gets the same 'helpful' treatment, wanted or not.

" It is our job (in part) to put distance between you and your self-destructive impulses."

You cannot put distance between a person and their impulses, those impulses are inherent to the individual. They are intrinsic, not discreet. This is the kind of semantic nonsense that psychiatry peddles as help? What you really mean is that it is our job to dampen those impulses via techniques akin to brainwashing: i.e. isolate the patient/victim, remove their autonomy, their decision-making capability, their relationships, even their surroundings. Give them a minor trauma - the reality of involuntary hospitalization - and treat them like a child instead of an adult (Grounding a child becomes involuntary commitment, taking away privileges becomes taking away rights; really, the similarities are remarkably transparent) and maybe they will start to identify with you? Agree with you? Kind of a Stockholm Syndrome effect, perhaps? This is what you offer?

" However, if you come to a psychiatric facility (or post on the internet) and argue with me that your suicide plan is rational, I'll take that to mean you have mixed feelings about it — why else would you expend such effort to sway someone you don't even know?"

First - rational: using reason or logic in thinking out a problem - so, yes, it can be rational. You just refuse to accept that, because it doesn't agree with your personal viewpoint - now who's being irrational? As far as mixed feelings; well, we all have mixed feelings about a great many topics and decisions. That doesn't mean that we all want the opposite of what we choose. Au contraire, we usually weigh the options and make a decision, and not always the optimal one. That's human nature. But, we still make a decision. Our decision, not someone elses.
Finally, why would I expend the effort? I don't know, why do you? Why do you go to such lengths to force your worldview on someone who obviously has a different outlook? That is, after all, the crux of the argument; the pros and cons of suicide. You have one view, I have another. You are here arguing your view, I am countering with a different view. Yet you read more into mine? If I am here arguing from a will to live, based on my opinions, then by default you must be arguing from a desire to die, based on yours. Why else are you here but because of your mixed feelings about the subject?
See how easy that bit of reasoning is to use? In the end, your 'help' is a burden I am not interested in carrying of. Count on that.

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Posted by Je Suis to Shrink Rap at August 09, 2013

Je Suis said...

@Simple Citizen

"though people are on legal holds and don't have the right to choose to leave, they still have the right to refuse medications, refuse invasive procedures, lab draws, etc"

True enough, albeit in a somewhat limited fashion; after all, if it is deemed an emergency, or if it is determined that the person being held lacks the capacity to make those decisions for themselves, then the their ability to refuse becomes somewhat less than concrete, to put it mildly. Perhaps more importantly, the refusal itself can lead to a prolonged stay, as it can be viewed as resisting treatment - treatment that the clinician, but not the patient, has the capacity to decide on, the same clinician who can play a waiting game with the patient by keeping them in captivity while going free themselves. Given enough time, the patient will accede to the demands placed upon them in order to escape their confinement. The incredible boredom and general lack of anything remotely stimulating in the facilities holding these individuals virtually guarantees this. I have mentioned this before, but it bears repeating: these techniques are nearly identical to brainwashing. Take away their power to make even basic decisions for themselves, isolate them and make them dependent for their basic needs, refuse any kind of intellectual stimulation, focus them on the reasons that they cannot leave and how they must comport themselves in order to do so - eventually, even the most stalwart resistor will begin to crack. So much for voluntary.

Anonymous said...

Simple Citizen, it scares me, too. There should be action taken against staff who, for whatever reason, coerce and/or threaten patients in order to get a signature on paper. I don't have a lot of empathy for those who cut corners and violate patient rights to save themselves some paperwork. I remember days when I had to stay late because I had concerns that the person did not understand and/or agree with what was in the informed consent. I stopped the process and paged the physician. I did not obtain a signature, even though in most cases I could have. I also never threatened or coerced anyone to sign a consent. People have to do the right thing, no matter time it is, and no matter how tired they are.

I do wonder if patients on legal holds (and those who are held involuntarily even though classified as "voluntary") all feel that they have the right to refuse medication. I remember thinking that if the staff would threaten me to get me to sign a consent form, then what else could they do. I wonder if some patients are experiencing the same coercion when it comes to medication, and if so then patients may not realize they can refuse it.

In my situation it was not the physician who threatened me to obtain consent; I am not even sure he was aware. I believe she was a social worker if I remember correctly.


navy4ever said...

Great discussion! And yes, I know this thread is 2 years old ;-)

The assertion that advance directives are only valid for terminal patients is news to me!! You need to give a source or precedent for that.
To knowing disregard a valid advanced directive is risky. You're opening yourself up for an ethics investigation, a civil lawsuit, and criminal charges for battery.