PSYCHIATRIC DIMENSIONS OF MEDICAL PRACTICE: COMPETENCE TO REFUSE MEDICAL ADVICE-WHEN THE PATIENT IS COMPETENT
PSYCHIATRIC DIMENSIONS OF MEDICAL PRACTICE: COMPETENCE TO REFUSE MEDICAL ADVICE-WHEN THE PATIENT IS COMPETENTThe refusal of competent patients to follow medical advice is understandable when, for example, they lack information, are ambivalent about a risky procedure, or wish the opinion of another physician. Refusals of this type may be more common when patients feel as if they are being carried along on a kind of therapeutic conveyor belt, without an opportunity to influence the speed or direction of events. In these cases, an evaluation for competence can help patients reverse their decisions, perhaps because the physician now offers more detailed explanations, speaks directly to the patient’s concerns, or apologizes for not having had a more satisfactory discussion before. Sometimes, however, nothing the physician can do will change the patient’s mind. This may occur when the latter’s personality is so rigid that accommodation is impossible, as the following case illustrates. The Case of Mr. J.-Mr. J., a 22-year-old man with acute myelogenous leukemia, was referred to the psychiatric consultation service for evaluation of competence to leave the hospital against medical advice. The patient’s father and several cousins abused alcohol, but family history was otherwise negative for psychiatric disorder. Mr. J.’s childhood had been healthy, though his upbringing was chaotic because of his father’s drinking. The patient quit school in the eleventh grade, but had later obtained a general equivalency diploma. He worked as a salesman in a department store and, after several years of steady employment, had established an independent existence. Mr. J. was unmarried, but had been in a romantic relationship for two years. He lived alone and had no contact with his family. The patient did not use alcohol or illicit drugs. He was without religious affiliation. Mr. J. described himself as a cheerful person who was a “go-getter” and a “hard worker.” He was proud of having pulled himself up by his bootstraps. There was no past psychiatric history. Mr. J. had never been seriously ill and so was puzzled three months before admission when he developed fever, progressive fatigue, and bleeding gums. After a course of antibiotics had failed to produce improvement, the patient went to an emergency room, where his white blood cell count was found to be 160,000. He was transferred to the Johns Hopkins Oncology Service and the diagnosis of acute myelogenous leukemia was made. After leukophoresis was done, induction chemotherapy was given. Mr. J. quickly revealed a fatalistic attitude about his illness and requested not to be intubated or resuscitated. Throughout his hospital course the patient was worried about missing work, for without an income he could not pay for his apartment or new car. He refused to apply for Social Security benefits because he did not want to take charity. As his hospital stay lengthened from days to weeks, he talked of leaving against medical advice but never did so, despite the unpleasant sequelae of chemotherapy. Mr. J. was discharged after a month’s stay. Though his leukemia was in remission, he did not feel well enough to work. Five weeks later, the patient was readmitted for consolidation chemotherapy. He again requested not to be intubated or resuscitated. This time, his treatment was followed by worrisome and persistent problems, the most distressing of which were nausea, vomiting, and severe, embarrassing diarrhea. Because of this last complaint, Mr. J. had to wear a diaper and stay in his room. He was again preoccupied with his debts, which now included bills from his previous admission. Under the circumstances, Mr. J. decided to apply for Social Security benefits. As his hospitalization entered its third week, the patient’s mood became increasingly sad and irritable. He stopped talking to certain members of the staff and began refusing treatments (e.g., antiemetics) and diagnostic procedures (e.g., arterial blood gases). When psychiatric consultation was suggested he refused that, too. Mr. J. was given emotional support and encouraged to voice his concerns as soon as they arose. His mood improved when his girlfriend visited, but she seemed to be a passive person and never became involved in his care. On the day before psychiatric consultation, Mr.J. threatened to leave the hospital against medical advice. His physicians persuaded him to stay, but the next day he renewed the threat, saying that his situation was intolerable: “I’ve always had a hard life and I just can’t take this anymore.” He thought that if he could get out of the hospital, he might be able to recover more quickly. Mr. J. now agreed to psychiatric consultation, which his physicians requested despite their belief that he was competent to be discharged. On mental status examination Mr. J. was an alert, grudgingly cooperative young man who made good eye contact. He lay quietly in bed and appeared fatigued, but there were no psychomotor abnormalities. The patient spoke a moderate amount, both spontaneously and in reply to questions. Speech was prompt, brief, and without evidence of thought disorder. Mood was described as “calm” and assessed as slightly irritable. Affect was somewhat constricted, but appropriate to the content of speech. Mr. J.’s self-esteem was intact and he was hopeful about the future. He denied “passive death wishes,” suicidal thoughts, homicidal thoughts, hallucinations, delusions, obsessions, compulsions, and phobias. MMSE score was 27/30. Mr. J. said that he had agreed to the consultation to satisfy his doctors that he was sane. He spoke feelingly about his sense that all he had worked for was coming undone, that his bills were growing while he was in the hospital, that he was frustrated at being confined to his room by diarrhea, and that he could not decide anything for himself—not even what he ate. He understood that he needed treatment for the sequelae of chemotherapy but thought he would do better in a less restrictive setting. My impression was that Mr. J. had been demoralized by his situation, a situation that was especially difficult for him because of his independent personality. Although his self-reliance had been helpful in other areas of his life, it was now undermining his treatment. I thought Mr. J. was unwise, but not incompetent, and that he might agree to stay in the hospital if he were given greater control over certain aspects of his care, such as his diet. Mr. J.’s physicians and nurses agreed to do what they could to accommodate his wishes. For a time, he was in better spirits, was more cooperative with staff, and spoke less often about leaving the hospital. Several days later, however, when his nausea and vomiting had stopped, his diarrhea had improved, and he was scheduled to begin a regular diet, Mr. J. demanded to leave and was discharged against medical advice. Although he came regularly for outpatient visits as long as he needed transfusions, Mr. J. eventually began skipping appointments because he was worried about physicians’ fees and the cost of laboratory tests. A few months after discharge, when his leukemia was in remission and he had returned to work, the patient dropped out of follow-up entirely. Several months after that, the leukemia recurred and he was hospitalized again. This time Mr. J. was very cooperative with treatments and diagnostic procedures, but he died on the thirteenth day of admission.*64\172\2*
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