Assessing Patient Sanity

Some mental capacity assessment tips for physicians, especially new practitioners and resident doctors.

Imagine a patient who leaves the hospital against your advice and ends up harming themselves.

You might have had the patient document on an against medical advice (AMA) form so your license seems protected, but you are still going to feel terrible with a bad outcome. Moreover, a court of law may still prosecute you if they disagree with your assessment of the patient’s decision making capacity to leave the hospital in the first place. Hence, this is worth the quick read.

AMAs are not a rare occurrence (in 2019-2020 there were 133,445 AMA discharges, or 2.6% of all discharges in the U.S.), and they pose a special problem because of the time constraint we physicians have to make a determination of patient capacity. This is especially true in the ER when we’re seeing sometimes upward of ten-patients-per-hour in the first few hours.

Cases that are complex clinically compound the problem. For instance, consider an elderly person with early dementia and a UTI causing severe sepsis. They now have a combo of acute and chronic problems potentially impacting their cognitive executive functioning. They may say something that seems to reflect some understanding: “Hey buddy, I’m old, let me out of here”. They may refuse to communicate more than a few sentences, and can parrot a few statements about their medical problem back to you.

But are they in their right mind? Are they required to explain themselves? Is it the UTI or the dementia messing with their mind, or both? Is their dementia severity to the point it already strips them of decision making capacity? All can be tough to answer...

The key to assessing a patient’s capacity is evaluating their insight into their illness.

Equally important is that the more serious the decision, the more insight the patient must demonstrate.

For example, a patient with ongoing ventricular tachycardia must fully understand the likely fatal consequence of cardiac pump failure from arrhythmia within 24-hours if leaving the hospital without treatment. In contrast, minimal insight is needed for refusing a topical treatment for a mosquito bite.

To assess insight, listen to the patient recapitulate their diagnosis, treatment options, and risks in their own words. Patients with advanced dementia might repeat parts of what you say but cannot summarize it meaningfully. If a patient can provide a reworded version of your explanation and reason their risky choice, they likely have adequate insight.

Consider a ninety-eight-year-old patient who understands the high risk of death without hospital admission but chooses to go home. You cannot take away their right to make this choice, regardless of your moral stance. While not required, asking a patient to explain their reasoning can be helpful, especially if their capacity is in doubt.

A few ideas that may help you avoid resorting to AMA forms…

Kindly inquire about their reasons for refusing care. Sometimes the act of genuine inquiry is enough to persuade a patient to stay. Then address their concerns, no matter how small. Get blankets, reposition their bed, get them food if they can eat. Help them make a call to family. Order nicotine patches and reassure them you can expeditiously treat all types of withdrawal if they have substance dependence issues.

Finally, call people who know them best to advocate on your behalf (sometimes I do this on speakerphone in front of the patient, with their permission of course).

You will find it useful to contact the their providers or family. Docs who know them may have previously implored idiosyncratic strategies. Spouses also have a way of quickly snapping some sense into their loved one.