New York Program Benefits Mentally Impaired Patients

Psychiatrist Michael Dempsey, M.D., faced an urgent problem—a patient with schizophrenia who was experiencing delusions had developed a massive hernia.

The patient denied having the hernia and refused an operation to repair it. “He would not consent to what he did not have,” said Dempsey, medical director of the Columbia County Clinic in Hudson, N.Y., and a clinical psychiatrist at the Capital District Psychiatric Center in Schenectady, N.Y.

Thus, considering that the patient lacked the capacity to make a decision about a needed medical procedure and did not have anyone authorized to provide consent, Dempsey had to decide how to obtain authorization for the patient’s medical treatment to proceed.

If this scenario had occurred in New York state before 1986, Dempsey would have had no choice but to go through the court system, a process that could have taken weeks. In fact, in public hearings conducted in 1984 by the New York State Commission on Quality of Care for the Mentally Disabled, some witnesses reported that they routinely waited several months to obtain court authorization for surgical procedures, and others reported waiting as long as 57 days to obtain authorization for other major medical procedures.

Due in part to these delays, the commission created the first program in the nation to serve as an alternative to such court proceedings: the Surrogate Decision-Making Committee (SDMC) program, in which a panel of four specially trained volunteers conducts a quasi-judicial hearing and then authorizes or refuses consent for the patient’s nonemergency major medical treatment.

From its statewide listing of more than 950 volunteers, the commission convenes such a panel in the region where the patient resides. The panel consists of a health care professional such as a psychiatrist or a nurse; an attorney; a former consumer of mental health care or development disability services or a family member of, or advocate for, individuals with mental illness or developmental disabilities; and an individual with expertise or interest in services for individuals with mental illness and/or developmental disabilities.

During the hearing, panelists evaluate documents and listen to testimony. They render up to three decisions.

First, they decide if the patient has the capacity to make his or her own medical decision. Second, if the patient is determined not to have that capacity, the panel determines if he or she has a surrogate authorized to make such a decision. Finally, if no such surrogate exists, the panel determines if the treatment is in the best interest of the patient. Its overall goal is three-fold: to protect the patient’s autonomy, ensure due process, and consider the patient’s best interests.

Unless the case is complicated, the panel issues its decision immediately after the hearing, and the paperwork in support of the decision is available that day, Tom Fisher, director of the SDMC program, told Psychiatric News.

The program serves individuals diagnosed with mental illness or developmental disabilities who receive services from facilities licensed, operated, or funded by the New York State Office of Mental Health or the Office of Mental Retardation and Developmental Disabilities (OMRDD). It also serves individuals from facilities to which those offices have distributed federal funding. About 90 percent of these individuals are from the OMRDD facilities.