Clinical Issues in the Assessment of Competency

Ms. A, a 74-year-old unmarried retired medical secretary with a history of three acute psychotic episodes, had a residual paranoid delusional system that could be diminished but not eliminated with medication. She lived in a nursing home.

Two weeks before psychiatric consultation was requested, a routine physical examination at the nursing home revealed a large lump in Ms. A's left breast, with retraction of the nipple. A surgical consultant recommended biopsy and probable mastectomy. The surgeon discussed the procedure with the patient and was satisfied that, especially in the light of her familiarity with medical terminology, he had obtained informed consent to the procedure from her. The administrators of the nursing home, however, concerned about their liability, requested that a formal psychiatric assessment of her competency be made and arranged an appointment for the assessment.

When Ms. A arrived at the psychiatric clinic for the evaluation, accompanied by the continuing care nurse who followed her regularly, she disclosed that since meeting with the surgeon she had received a phone call from him saying that she did not need the surgery, that he had recommended it only because his wife needed more money, and that her nephew—her closest relative, who acted as conservator of her funds—wanted her to undergo the procedure so that she would die sooner and he could take her money. A call to the surgeon's office revealed that the alleged phone call had never taken place. Nonetheless, the patient clung to her story and refused the procedure. It was the examiner's opinion that her refusal was based on her delusional beliefs and that it appeared to be incompetent. He and the nurse agreed to explore the possibility of the nephew's acting as guardian to give substituted consent for the procedure.

A repeat surgical examination 2 weeks later showed that the lump was expanding rapidly, that there was danger of ulceration through the skin, and that surgery was urgently needed. The patient's nephew, fed up with her accusations that he was stealing her money, had declined to act as guardian, and the option of approaching the court directly for permission to operate was being investigated. The psychiatrist decided to reevaluate the patient, who had indicated some willingness to proceed with surgery: the reassessment took place one month after the initial assessment.

Although still clinging to her story of the phone call from the surgeon, she now maintained that she was basing her continued refusal of surgery on other grounds: 1) she was afraid of dying during the operation, and 2) she felt that she had led a full life and was willing to take her chances on not removing the apparent cancer, which she recognized could lead to her death. The examiner's impression was that she still was delusional but that her refusal was based on rational reasoning and therefore was probably competent. A clinical conference with a senior clinician and the hospital's attorney was arranged to review the case.

At the conference, the patient discussed her fear of the operation in terms that emphasized her dread of being abandoned by all of her caretakers and left to die. Just as all her acute psychotic episodes had been provoked by interpersonal losses and her paranoid delusions and hallucinations had always seemed to serve a restitutive function, so it appeared that her psychotic response to the recommendation for surgery was an attempt to draw those around her into deeper involvement. When these concerns were pointed out to her and empathized with, she indicated that although she still feared the surgery, she would accept it. It was agreed that the continuing care nurse would continue to visit her often and would accompany her to the surgeon^,s office, where her formal consent would be obtained.

The biopsy performed after consent was obtained revealed a carcinoma: an extended simple mastectomy was performed. The patient recovered from the surgery without medical complications and without exacerbation of her psychosis.

This woman's fears had been aroused by the peculiar latent meaning that a mastectomy held for her: that it would be a stimulus for those around her to withdraw, leaving her alone with nothing but death ahead of her. As her fears were explored in a setting she could trust, she was able to relinquish her need for psychotic mechanisms of defense, to be reassured that her fear of the results of the surgery was unrealistic, and to provide reasonable consent to a procedure that was manifestly in her best interest.

The interpersonal consequences of the proposed procedure do not represent the only basis for the development of psychotic ideation.

Ms. B, a 43-year-old woman diagnosed as schizophrenic, had long-standing bilateral glaucoma. In one eye, vision remained only for motion. Because the intraocular pressure in the other eye, which had better vision, was poorly controlled by medication, the patient's opthalmologist proposed a drainage procedure for that eye.

Although Ms. B was worried about the pressure in her eye and fearful of going blind, she refused the drainage procedure, explaining that her “voices” would be “angry with her” if she underwent the procedure. When her reasons for refusal were explored further, the patient noted that her mother had had a similar drainage procedure for glaucoma that had not been helpful. The patient then discussed her attachment to her mother, noting in a symbiotic and concrete fashion that she knew that whatever happened to her mother would also happen to her.

The suggestion for glaucoma surgery in this case appeared to provoke a threatening identification with the patient's mother, a merger that the patient's “voices” resisted by commanding the patient to refuse the operation. While the identification of this dynamic was not in itself sufficient to allow the patient to drop this defensive posture, it did clarify the basis for her refusal and confirmed its psychotic and therefore apparently incompetent nature. Failure to explore the basis for the patient's refusal would have left this point in doubt. An assessment of the psychodynamic basis of the patient's refusal should be part of every competency examination.

Ms. C, a 51-year-old woman, was committed to the hospital after she threatened to harm her husband. The patient had been falsely accusing her husband of having multiple marital affairs. When initially evaluated at the hospital, the patient looked quite well and denied illness or any impairment in her thinking. It was only when additional data were obtained from her husband and her physician (both of whom had for 2 years had progressive difficulty coping with her delusions and escalating paranoia) that the nature of the patient's problem became more evident. The psychiatrist learned from the patient's husband and physician that the patient had been expressing many delusional beliefs and was acting peculiarly at home. e.g., she had believed that her former physician had been taking her to the woods to have sex with her in the company of other doctors: she now believed that her husband was the father of all her sister's children.

As a rule of thumb, the competency assessment should be considered incomplete unless the patient's history has been authenticated by someone who is familiar with his or her behavior in his or her natural environment. Such a procedure not only confirms the accuracy of the factual data but also serves as a yardstick by which to measure the nature of the patient's appreciation of his or her illness or, conversely, the magnitude of the patient's denial.

Mr. D, a 37-year-old man, was admitted to the hospital after being struck in the head during a robbery. He sustained a basilar skull fracture, and a CT scan revealed a left frontal epidural bleed. The patient signed a consent form agreeing to craniotomy and evacuation of the left epidural clot. The next day, however, he refused the procedure, indicating that he wanted “a few more days to think it over.” He also said that he wished to leave the hospital against medical advice. When discussing the proposed surgery with a psychiatric consultant (who had been asked to evaluate the patient's “competency” to refuse). Mr. D made many offhand comments that were difficult to analyze, e.g., he noted with respect to the consequences of his refusal that. “Of course, everyone dies.” It was unclear to the psychiatric consultant whether the confused responses were the result of the inadequacy of the information previously given to the patient about the procedure or whether the patient's indifference to his outcome was the consequence of brain dysfunction and injury. Only when the patient was reinterviewed by his neurosurgeon, who told him slowly and in great detail about the proposed procedure, did it become clear that the patient could not understand. He believed that his previous discussions with the neurosurgeon had been about the subject of “getting a loan.”

The psychiatric consultant should insist that an explanation or reexplanation of the relevant material take place in his or her presence. Preferably, this should be done by the physician who is primarily responsible for the patient's care. This not only aids in helping to explain a patient's distortion, lack of understanding, or confusion, but will also help to clarify for the consultant the precise nature of the issues involved, including their urgency. Affective indifference on the part of a patient who is faced with a recommendation for immediate treatment may raise even greater doubts about a patient's competency than would a similar reaction from a patient who has been told that the suggested procedure is partly elective.

Mr. E, a 55-year-old man, was admitted to the hospital virtually mute and with urinary retention. A thorough medical workup revealed no cause for the patient's condition save depression. At times the patient talked spontaneously about communications from outer space. He was otherwise unresponsive to staff questioning. The staff attempted to explain his illness to him and to solicit his consent for ECT. The patient made no response whatsoever to this information. Because the patient was not eating or drinking, immediate administration of ECT was judged necessary. The patient seemed obviously “incompetent.” It was decided that an emergency hearing to evaluate his competency should be scheduled. One day later (before the court hearing could be scheduled), however, the patient began to talk. He indicated that he simply “hadn't felt much like talking over the last few days.” He was, at this time, able to give a complete medical history and to discuss comprehendingly the risks, benefits, and alternatives of receiving ECT. Before the treatment could be started, however, Mr. E again became mute.

Ms. F, an 18-year-old girl diagnosed as schizophrenic, was admitted to the hospital after a family argument. Her urine test for pregnancy was positive. The staff wanted to discuss the possibility of abortion with the patient but was unsuccessful in doing so. She spent much of her time staring into space and playing with her fingers. She responded to the simplest questions with jargon or irrelevant answers. For example, when asked to give the names of her friends or family, she responded, “1 can't get past my big teeth.” Because of her pregnancy, it was decided not to treat the patient with medication but to continue to observe her in the hospital. She improved considerably over the next week. Although her speech remained somewhat tangential, she nevertheless became able to discuss what abortion meant to her and to indicate that she might want to have the baby and then give it to her sister to raise.

Whenever the assessment of competency is being conducted in a nonemergency setting, more than one evaluation session should take place. Had this rule not been followed for Mr. E, Ms. F, and Ms. A, depending on when the evaluation took place, the psychiatrist could have arrived at one of a number of mutually exclusive conclusions: that the patient was offering competent consent, incompetent refusal, or competent refusal or was not sufficiently competent to evidence a choice at all. The magnitude of the intrusion on a patient's autonomy that is represented by the consequences of a finding of incompetency and the impact of allowing a competent patient to refuse potentially life-saving treatment both argue for a cautious approach to evaluation of competency, represented by at least two contacts with the patient on at least two different days.

Ms. G, a 26-year-old black woman with juvenile-onset diabetes, was admitted to the hospital with cellulitis of the leg. She had had many previous surgical procedures, including amputation of all her toes and partial amputation of one hand. The patient was extremely angry when admitted to the hospital. She would not talk and refused an intravenous line, antibiotics, and to have her leg dressed. The psychiatric consultation service was called to see the patient to evaluate the nature of her refusal and her “competency to refuse.” This was impossible to do because the patient would not talk to the psychiatric consultant, who was white. After being evaluated by a black medical resident, however, the patient became somewhat more cooperative. She began eating and drinking, even though she would not accept other treatment. It was only after meeting and discussing her situation with a black hospital maintenance worker (whom she had known previously) that she became more cooperative and more willing to talk about her need for intravenous antibiotic therapy. She continued to show no interest in psychiatric consultation.

This kind of difficulty is more likely to arise when patient and physician are of different races or of disparate social classes, but whenever there is reason to believe that interpersonal factors are affecting the patient's ability to formulate a competent decision, the assessment should be performed again with the assistance of someone who is more likely to be found congenial by the patient. The same applies, of course, if the patient displays an antipathy for the psychiatrist who is undertaking the competency assessment and refuses to “perform” for him or her.