Capacity evaluation for Covid Deniers?

[Mass Effect]

****NOT A POLITICAL THREAD****

This is a real thing and I bet other people have encountered this or thought about it. Let's leave politics out so this thread doesn't get closed. A colleague on call this morning got a capacity consult for a Covid + patient on 3L but with several co-morbidities that increases risk of rapid decompensation wanting to leave AMA because she doesn't believe in Covid. Team tried telling her she's got pneumonia leaving Covid out of it, but she refuses to believe it because she thinks Covid was created to defeat Trump. She knows she's sick, but she doesn't think it's serious because Covid doesn't exist and she wants to wait it out at home. She is otherwise fully with it with no concern for acute or chronic mental illness or cognitive disorder. Colleague suggested no capacity due to inability to appreciate seriousness of her condition and inability to weigh risk and benefit, but team attending disagreed if its based just on that because he doesn't think "politics should play a role in eliminating someone's autonomy to make medical decisions".

What say you? I thought it was a slam dunk but others disagree. Are other people getting these?

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[90sportsfan]

I think this is a very relevant post for the Psychiatry forum. One thing that has been getting me, and I always think about, is the people who are even about to die, and will still refuse to believe they have COVID or want to get treatment for it. And there have been countless unfortunate stories like this. It’s almost like they are willing to die rather than give in to the realities of COVID. This pandemic has been a case study across all areas of life. I’m glad you posted this because I’m curious as a future physician what the psychological etiology of something like this is and what can be done to address it.

*Note- this is not ignoring the true questions/concerns that many (especially non-medical) may have about COVID, vaccines, masking, etc.

 

[EatSleepForensics]

****NOT A POLITICAL THREAD****

This is a real thing and I bet other people have encountered this or thought about it. Let's leave politics out so this thread doesn't get closed. A colleague on call this morning got a capacity consult for a Covid + patient on 3L but with several co-morbidities that increases risk of rapid decompensation wanting to leave AMA because she doesn't believe in Covid. Team tried telling her she's got pneumonia leaving Covid out of it, but she refuses to believe it because she thinks Covid was created to defeat Trump. She knows she's sick, but she doesn't think it's serious because Covid doesn't exist and she wants to wait it out at home. She is otherwise fully with it with no concern for acute or chronic mental illness or cognitive disorder. Colleague suggested no capacity due to inability to appreciate seriousness of her condition and inability to weigh risk and benefit, but team attending disagreed if its based just on that because he doesn't think "politics should play a role in eliminating someone's autonomy to make medical decisions".

What say you? I thought it was a slam dunk but others disagree. Are other people getting these?

Very interesting scenario. I have (at least) a few questions: 1) Does she accept the diagnosis of pneumonia, and if not, on what basis does she refute it, exactly? 2) Related to #1, does she demonstrate the capacity to acknowledge/apply information about her comorbidities and their associated risks relevant to pneumonia? (details could also matter here, of course) 3) How did she get to the hospital in the first place? Did she seek care of her own accord? 4) Does she describe how she envisions "waiting it out at home" and her thinking about a prospective return to the ER?

 

[thepoopologist]

The team attending is equating capacity and autonomy when in reality what they're saying is that patient autonomy outweighs the patients lack of decision making capacity. The problem is the patient doesn't appreciate how seriously sick she is despite the oxygen supplementation and therefore can't appreciate the consequences of what will happen when she leaves. Another complicating factor, if she leaves AMA and there is a consult from psychiatry saying she lacks decision making capacity then that leaves wiggle room for the family to say lack of decision making capacity should've been considered more than her autonomy if she dies. If she's held against her will based on decision making capacity now you have a person and possibly her family also who will be fighting the team every step of the way

Note: My terminology might not be exact but hopefully my rationale is. I think the other thing the consider is whether patient autonomy is only valid if the patient has decision making capacity, frankly this should be the conclusion.

 

[Mass Effect]

Very interesting scenario. I have (at least) a few questions: 1) Does she accept the diagnosis of pneumonia, and if not, on what basis does she refute it, exactly? 2) Related to #1, does she demonstrate the capacity to acknowledge/apply information about her comorbidities and their associated risks relevant to pneumonia? (details could also matter here, of course) 3) How did she get to the hospital in the first place? Did she seek care of her own accord? 4) Does she describe how she envisions "waiting it out at home" and her thinking about a prospective return to the ER?

The information I have from earlier texts is that she came to the hospital due to familial pressure. Her brother, sister and mom want her kept and say she's gone down the QAnon rabbit hole and are afraid of losing her to this. Patient was not asked details about QAnon but didn't say anything to overtly tip my colleage off that she has any delusions in that regard (but even if she did, that would still be political in some respect right?). Patient accepts she has pneumonia but believes she is getting better and in fairness, her O2 sats have improved since admit. They thought she'd need intubation when in the ED but ended up not. She does not believe her co-morbid CAD, HTN, HLD, COPD, obesity will be a risk factor because she does not believe in Covid and does not believe other forms of pneumonia are affected by these. She's apparently had pneumonia before way prior to Covid and thinks it's the same. Don't know anything else.

 

[EatSleepForensics]

The information I have from earlier texts is that she came to the hospital due to familial pressure. Her brother, sister and mom want her kept and say she's gone down the QAnon rabbit hole and are afraid of losing her to this. Patient was not asked details about QAnon but didn't say anything to overtly tip my colleage off that she has any delusions in that regard (but even if she did, that would still be political in some respect right?). Patient accepts she has pneumonia but believes she is getting better and in fairness, her O2 sats have improved since admit. They thought she'd need intubation when in the ED but ended up not. She does not believe her co-morbid CAD, HTN, HLD, COPD, obesity will be a risk factor because she does not believe in Covid and does not believe other forms of pneumonia are affected by these. She's apparently had pneumonia before way prior to Covid and thinks it's the same. Don't know anything else.

Okay - understanding you may not know the answers: why the urgency to leave? I mean, what is the team's proposed treatment plan and, if they've projected, the likely timeframe for it, and how is she arriving at the wish to leave abruptly?

 

[Mass Effect]

Okay - understanding you may not know the answers: why the urgency to leave? I mean, what is the team's proposed treatment plan and, if they've projected, the likely timeframe for it, and how is she arriving at the wish to leave abruptly?

Don't know. One thing my colleague said was that the patient never wanted to come to the hospital. She only came to get an "all clear" from the ED so her family would get off her back.

 

[EatSleepForensics]

Don't know. One thing my colleague said was that the patient never wanted to come to the hospital. She only came to get an "all clear" from the ED so her family would get off her back.

I'd be inclined to say she lacks capacity and to draw attention to her inability to manipulate medical facts even in isolation from her ideological views.

 

[calvnandhobbs68]

****NOT A POLITICAL THREAD****

This is a real thing and I bet other people have encountered this or thought about it. Let's leave politics out so this thread doesn't get closed. A colleague on call this morning got a capacity consult for a Covid + patient on 3L but with several co-morbidities that increases risk of rapid decompensation wanting to leave AMA because she doesn't believe in Covid. Team tried telling her she's got pneumonia leaving Covid out of it, but she refuses to believe it because she thinks Covid was created to defeat Trump. She knows she's sick, but she doesn't think it's serious because Covid doesn't exist and she wants to wait it out at home. She is otherwise fully with it with no concern for acute or chronic mental illness or cognitive disorder. Colleague suggested no capacity due to inability to appreciate seriousness of her condition and inability to weigh risk and benefit, but team attending disagreed if its based just on that because he doesn't think "politics should play a role in eliminating someone's autonomy to make medical decisions".

What say you? I thought it was a slam dunk but others disagree. Are other people getting these?

So based on the info here, it's not clear she has capacity. Totally leaving the COVID thing out of it, just from the get-go if she can't express clearly that she understands leaving the hospital may come with a risk of serious decompensation or death with severe pneumonia of any sort, she's not demonstrating an appropriate understanding of the condition and thus it's not even clear she could use her understanding of the condition appropriately to apply to her own situation.

It's actually interesting because this is actually somewhat nuanced. One interesting question to ask if she could detach from the current situation might be what course of action she would take if she was hospitalized with S. aureus pneumonia...so getting at is this just a COVID thing or does she really have such a poor understanding of the disease process in general.

The ideas of "I'm not sick from COVID because COVID doesn't exist" and "I'm not that sick at all in general" are kind of two different ideas to try to get at.

 

[EatSleepForensics]

So based on the info here, it's not clear she has capacity. Totally leaving the COVID thing out of it, just from the get-go if she can't express clearly that she understands leaving the hospital may come with a risk of serious decompensation or death with severe pneumonia of any sort, she's not demonstrating an appropriate understanding of the condition and thus it's not even clear she could use her understanding of the condition appropriately to apply to her own situation.

It's actually interesting because this is actually somewhat nuanced. One interesting question to ask if she could detach from the current situation might be what course of action she would take if she was hospitalized with S. aureus pneumonia...so getting at is this just a COVID thing or does she really have such a poor understanding of the disease process in general.

The ideas of "I'm not sick from COVID because COVID doesn't exist" and "I'm not that sick at all in general" are kind of two different ideas to try to get at.

Yes, this is a better-articulated version of what I was thinking. I've got to imagine these cases are indeed coming up not infrequently. Although fascinating, this vignette makes me relieved that I don't do hospital C/L work anymore.

 

[Bartelby]

In this case I actually think she has capacity to leave AMA. Unfortunately COVID denial is a subcultural belief in the US that is more of an extreme overvalued idea (Extreme Overvalued Beliefs) than a delusion. It sounds like she is currently at her highest level of function and is electing to follow her own belief system, similar to the way religious people might be deemed to have the capacity to opt for faith healing etc even when we strongly disagree medically. I would let her leave AMA with careful documentation of her intact cognition, lack of psychosis or delirium etc.

If she, for example, had a superimposed bacterial pneumonia and refused to acknowledge that then I think it would be a more grey issue because there is no large subculture promoting and accepting the idea that bacterial pneumonia is not real. That would likely land more in the realm of lacking capacity to me.

 

[Old&InTheWay]

In this case I actually think she has capacity to leave AMA. Unfortunately COVID denial is a subcultural belief in the US that is more of an extreme overvalued idea (Extreme Overvalued Beliefs) than a delusion. It sounds like she is currently at her highest level of function and is electing to follow her own belief system, similar to the way religious people might be deemed to have the capacity to opt for faith healing etc even when we strongly disagree medically. I would let her leave AMA with careful documentation of her intact cognition, lack of psychosis or delirium etc.

If she, for example, had a superimposed bacterial pneumonia and refused to acknowledge that then I think it would be a more grey issue because there is no large subculture promoting and accepting the idea that bacterial pneumonia is not real. That would likely land more in the realm of lacking capacity to me.

Totally agree with this. I also think there is a real risk of psychological harm in not letting her leave as holding her would likely feel to her as an act of political aggression, further alienating her from healthcare in the future.

 

[WisNeuro]

Totally agree with this. I also think there is a real risk of psychological harm in not letting her leave as holding her would likely feel to her as an act of political aggression, further alienating her from healthcare in the future.

I guess my only pause if I were doing the eval would be that from the details involved, it's not entirely clear if she appreciates the risk of the pneumonia and how her health negatively interacts with that risk.

 

[thepoopologist]

I think the idea is people should be able to decide whether they want to live or want to die as long as they understand what they're facing.

If someone has a belief system which impedes their ability to understand what they're facing, then it becomes a problem in the hospital setting depending on their degree of understanding, and the seriousness of what they are facing.

In her case it sounds like - to her - pneumonia is just a mild lung condition she has recovered from in the past, comorbidities be damned, and based on this and her lessening need for oxygen she has decided she is ok to go. I don't think there's an adequate understanding there, however two dynamic factors to consider
1. Her condition improves and this a sufficient argument that she is "correct" in her assessment and she goes.
2. Her condition worsens and this a sufficient argument that she is "wrong" in her assessment and she receives the treatment she needs

Also, I hate to say this, if it were me it would also depend on geographical region. If I was in a more qAnon Covid denial area and see the hospital yielding to patient autonomy regardless of decision making capacity and see the state and local governments backing this up, I'd let them go with a invitation to return if needed and document carefully. If I was elsewhere my decision would be more nuanced.

 

[calvnandhobbs68]

I guess my only pause if I were doing the eval would be that from the details involved, it's not entirely clear if she appreciates the risk of the pneumonia and how her health negatively interacts with that risk.

Right this is what we’re getting at.

In this case I actually think she has capacity to leave AMA. Unfortunately COVID denial is a subcultural belief in the US that is more of an extreme overvalued idea (Extreme Overvalued Beliefs) than a delusion. It sounds like she is currently at her highest level of function and is electing to follow her own belief system, similar to the way religious people might be deemed to have the capacity to opt for faith healing etc even when we strongly disagree medically. I would let her leave AMA with careful documentation of her intact cognition, lack of psychosis or delirium etc.

If she, for example, had a superimposed bacterial pneumonia and refused to acknowledge that then I think it would be a more grey issue because there is no large subculture promoting and accepting the idea that bacterial pneumonia is not real. That would likely land more in the realm of lacking capacity to me.

So I don’t think evaluating whether the COVID denial thing is a delusional belief or not even matters here. Delusional people have capacity to make medical decisions. The issue seems to be that she can’t even appreciate the severity of the medical condition in general. Which then impacts capacity to make decisions around that medical condition. If she could say “yes I understand that this is the severity of my current condition and yes I understand that I am at higher risk of dying if I leave the hospital today vs staying here” that would actually lends itself towards arguing that she would have capacity to leave AMA.

 

[WisNeuro]

I think the idea is people should be able to decide whether they want to live or want to die as long as they understand what they're facing.

If someone has a belief system which impedes their ability to understand what they're facing, then it becomes a problem in the hospital setting depending on their degree of understanding, and the seriousness of what they are facing.

In her case it sounds like - to her - pneumonia is just a mild lung condition she has recovered from in the past, comorbidities be damned, and based on this and her lessening need for oxygen she has decided she is ok to go. I don't think there's an adequate understanding there, however two dynamic factors to consider
1. Her condition improves and this a sufficient argument that she is "correct" in her assessment and she goes.
2. Her condition worsens and this a sufficient argument that she is "wrong" in her assessment and she receives the treatment she needs

Also, I hate to say this, if it were me it would also depend on geographical region. If I was in a more qAnon Covid denial area and see the hospital yielding to patient autonomy regardless of decision making capacity and see the state and local governments backing this up, I'd let them go with a invitation to return if needed and document carefully. If I was elsewhere my decision would be more nuanced.

I could care less what region it is, for me, I'm making the decision based on published guidelines for capacity evaluation that is easily defensible in court considering the increased chance of litigation in this instance.

 

[splik]

Right this is what we’re getting at.


So I don’t think evaluating whether the COVID denial thing is a delusional belief or not even matters here. Delusional people have capacity to make medical decisions. The issue seems to be that she can’t even appreciate the severity of the medical condition in general. Which then impacts capacity to make decisions around that medical condition. If she could say “yes I understand that this is the severity of my current condition and yes I understand that I am at higher risk of dying if I leave the hospital today vs staying here” that would actually lends itself towards arguing that she would have capacity to leave AMA.

it absolutely DOES matter. If the person doesn't have a mental disorder, then it doesn't matter whether they can't appreciate the severity of their condition or not. The whole point of decision-making capacity (and the reason why psychiatrists and psychologists are brought in to weigh on this question) is that we presume people have the ability to make decisions unless their is a reason to believe that their mental functions are impaired to the extent that they cannot. If you don't have a mental illness, neurocognitive disorder, or intellectual disability, then you still have decision making capacity even if you are unable to check all the boxes of the Appelbaum and Grisso criteria. Put simply, it is NOT enough to not communicate, understand, appreciate, and/or reason, but this deficit has to be due to a mental impairment. If the reason for the deficit is a cultural belief (i.e. an overvalued idea) then you have no justification for denying that patient their autonomy. decision-making capacity is fundamentally rooted in autonomy, because the whole point of evaluating capacity is to promote autonomy. If you allow someone to make a decision that they would have not made if they did have capacity, then you are depriving them of their autonomy as the decision is being fueled by delirium/psychosis/dementia etc. On the other hand, if someone has a deep personal conviction that is fundamental to their identity (for example being a QAnon believer who thinks COVID is a hoax to take down Trump etc), then that pt's beliefs about their illness, and subsequent decisions, even if they fly in the face of medical reality, are tied to that patient's autonomy and you have no justification to deny them their right to make decisions you disagree with if they aren't deemed to be psychotic.


It is unfortunate how poorly taught capacity evaluations are that so many psychiatrists do not appreciate this basic point.

ETA:

From Scott Kim's Evaluation of Capacity to Consent to Treatment and Research. Oxford: OUP, 2010

 

[WisNeuro]

it absolutely DOES matter. If the person doesn't have a mental disorder, then it doesn't matter whether they can't appreciate the severity of their condition or not. The whole point of decision-making capacity (and the reason why psychiatrists and psychologists are brought in to weigh on this question) is that we presume people have the ability to make decisions unless their is a reason to believe that their mental functions are impaired to the extent that they cannot. If you don't have a mental illness, neurocognitive disorder, or intellectual disability, then you still have decision making capacity even if you are unable to check all the boxes of the Appelbaum and Grisso criteria. Put simply, it is NOT enough to not communicate, understand, appreciate, and/or reason, but this deficit has to be due to a mental impairment. If the reason for the deficit is a cultural belief (i.e. an overvalued idea) then you have no justification for denying that patient their autonomy. decision-making capacity is fundamentally rooted in autonomy, because the whole point of evaluating capacity is to promote autonomy. If you allow someone to make a decision that they would have not made if they did have capacity, then you are depriving them of their autonomy as the decision is being fueled by delirium/psychosis/dementia etc. On the other hand, if someone has a deep personal conviction that is fundamental to their identity (for example being a QAnon believer who thinks COVID is a hoax to take down Trump etc), then that pt's beliefs about their illness, and subsequent decisions, even if they fly in the face of medical reality, are tied to that patient's autonomy and you have no justification to deny them their right to make decisions you disagree with if they aren't deemed to be psychotic.


It is unfortunate how poorly taught capacity evaluations are that so many psychiatrists do not appreciate this basic point

Is there case law with precedence that comes to this conclusion?

 

[calvnandhobbs68]

it absolutely DOES matter. If the person doesn't have a mental disorder, then it doesn't matter whether they can't appreciate the severity of their condition or not. The whole point of decision-making capacity (and the reason why psychiatrists and psychologists are brought in to weigh on this question) is that we presume people have the ability to make decisions unless their is a reason to believe that their mental functions are impaired to the extent that they cannot. If you don't have a mental illness, neurocognitive disorder, or intellectual disability, then you still have decision making capacity even if you are unable to check all the boxes of the Appelbaum and Grisso criteria. Put simply, it is NOT enough to not communicate, understand, appreciate, and/or reason, but this deficit has to be due to a mental impairment. If the reason for the deficit is a cultural belief (i.e. an overvalued idea) then you have no justification for denying that patient their autonomy. decision-making capacity is fundamentally rooted in autonomy, because the whole point of evaluating capacity is to promote autonomy. If you allow someone to make a decision that they would have not made if they did have capacity, then you are depriving them of their autonomy as the decision is being fueled by delirium/psychosis/dementia etc. On the other hand, if someone has a deep personal conviction that is fundamental to their identity (for example being a QAnon believer who thinks COVID is a hoax to take down Trump etc), then that pt's beliefs about their illness, and subsequent decisions, even if they fly in the face of medical reality, are tied to that patient's autonomy and you have no justification to deny them their right to make decisions you disagree with if they aren't deemed to be psychotic.


It is unfortunate how poorly taught capacity evaluations are that so many psychiatrists do not appreciate this basic point.

ETA:

From Scott Kim's Evaluation of Capacity to Consent to Treatment and Research. Oxford: OUP, 2010

I mean the flow chart isn’t even actually stating that. The only actual solid conclusion it comes to on the lower branches is “poor understanding” and “cannot determine that patient fails appreciation standard”…which is a much different thing than patient meets standard (as is noted up top).

Lacking capacity due to a psychiatric condition and lacking capacity are also separate things.

 

[WisNeuro]

I mean the flow chart isn’t even actually stating that. The only actual solid conclusion it comes to on the lower branches is “poor understanding” and “cannot determine that patient fails appreciation standard”…which is a much different thing than patient meets standard (as is noted up top).

Lacking capacity due to a psychiatric condition and lacking capacity are also separate things.

I can see splik's point in the frameof reference that I've never been consulted for a capacity eval where there was not a condition present, psychiatrically or medically, that had the potential to cause lack of capacity. In the case here, I'd argue that you have a condition present (pneumonia) that is known to cause delirium and altered mental status. The condition causing the lack of capacity does not have to be a chronic condition, it can be acute. Still, if after explaining the fact that a patient has pneumonia, and the risks of leaving AMA considering their medical condition at that present time, they cannot appreciate the risks/benefits, I am fine with levying my opinion as lack of capacity and letting the patient know that they can appeal to the hospital ethics panel if they wish.

 

[Mass Effect]

I can see splik's point in the frameof reference that I've never been consulted for a capacity eval where there was not a condition present, psychiatrically or medically, that had the potential to cause lack of capacity. In the case here, I'd argue that you have a condition present (pneumonia) that is known to cause delirium and altered mental status. The condition causing the lack of capacity does not have to be a chronic condition, it can be acute. Still, if after explaining the fact that a patient has pneumonia, and the risks of leaving AMA considering their medical condition at that present time, they cannot appreciate the risks/benefits, I am fine with levying my opinion as lack of capacity and letting the patient know that they can appeal to the hospital ethics panel if they wish.

No delirium or AMS. Patient is at baseline according to family.

 

[WisNeuro]

No delirium or AMS. Patient is at baseline according to family.

If someone explains her current risk with leaving AMA in plain terms, and she cannot relay that back and say that she understand that she is at an increased risk of death (if her current situation suggests so), I'd still maintain she lacks that appreciation and thus capacity in this instance. I'd document that there does not appear to be compelling signs of delirium, and I'd probably still mention and consult the hospital ethics committee. If they don't have a policy in place for this, I'm fine kicking the liability can down the road.

 

[Mass Effect]

If someone explains her current risk with leaving AMA in plain terms, and she cannot relay that back and say that she understand that she is at an increased risk of death (if her current situation suggests so), I'd still maintain she lacks that appreciation and thus capacity in this instance. I'd document that there does not appear to be compelling signs of delirium, and I'd probably still mention and consult the hospital ethics committee. If they don't have a policy in place for this, I'm fine kicking the liability can down the road.

The tricky part is that she understands what the doctors are saying. She just doesn't believe it. Whenever I've said a patient doesn't have capacity, it was because the patient could not understand the information due to impairment. She is not impaired. The doctor says "you will die if you leave" and she says "I won't die" but she understands that the doctors are saying that and that it is based on her illness. She apparently said she's a Christian woman and she has beat many a things in her life including pneumonia. She has faith this is the same and the doctors are exaggerating it and making it a bigger deal than it is so they could "put her down as a Covid number". Direct quote according to colleague. At one point she said they're probably writing everyone down as Covid even if they're there for a broken arm.

In the end the team let her go about an hour ago. Psych continued to suggest she stay but team didn't want to keep her "just because she doesn't believe in Covid" and psych team says that was the wrong decision. I can see where both teams are coming from. I don't know what my rec would've been if I had seen this case.

I think there is huge liability and if she dies the family who wanted her kept will sue. Who knows what a court will decide in this case. One could argue if she wasn't so delusional about Covid being made up for election fraud she would have stayed based on past behavior which was cooperative with her healthcare, doctor's recs and orders. But then again, are Covid and election delusions psych illness?

 

[nexus73]

Dismissal of reality in service of in group shared delusion and maintenance of pathologic narcissism.

But seriously. I think the real question, is the patient understanding they are actually having severe breathing problems and really could die, but despite this would rather go home and knowingly face the risk? OR are the flat out denying there is any risk, despite all evidence to the contrary? The former sounds like intact capacity and just a bad decision driven by political ideology. The latter sounds like no capacity, or at least inability to demonstrate capacity, for some reason. This nuance, and the ability to tease out the difference by effectively engaging the patient, is where the consult psych earns their keep I think.

Sometimes patients are just super anxious or angry and have no patience to have a meaningful discussion making capacity hard to determine. But if they can calm down after some reflective listening and empathy from a psychiatrist, and maybe a benzo, we can have a reasonable conversation.

 

[FlowRate]

Is the patient being physically held in the hospital/being prevented from leaving by security? Could she theoretically just stand up and walk out? What are her sats off of O2? Is she willing to work with the team to get home O2 set up? Does she have a baseline oxygen requirement related to the other comorbidities you mentioned? (COPD)

I'm agreeing with Barelby and splik at the moment. The current information provided indicates she likely has capacity. I suspect she's not in the dire straights that are being implied and team affect about covid denial and feeling that their efforts with the pt have been futile/frustrating are leading to a desire to punish the patient/enforce their "medical reality."

Make the case not about covid. A pt has a serious but not immediately life-threatening infection (but not something like active TB which would potentially require forced quarantining). The team thinks the patient stands a reasonable chance of dying in the next 1-2 weeks if the pt does not receive IV abx for another 5-10 days. The patient has been on abx for 3 days, they know they have an infection, they think it's getting better (it actually is getting better, with IV Abx), and they can wheel themselves out of the hospital. The patient initially presented for care at the advice of their family, went along with the first few days of hospitalization, and can reasonably be expected to be capable of the same choices after they leave the hospital. The team really wants the pt to stay inpatient to finish the abx and ensure the infection clears. The patient is antsy and categorically refuses the option of staying in the hospital for IV abx. IMO that pt has capacity and I've had plenty of pts leave AMA under such circumstances. Capacity is the default assumption until proven otherwise.

I touched on it earlier, but the team could be encouraged to take an approach where they assure the pt that the hospital is always ready to have her back if she needs their help and they do their best to support the pt's decision (help with arranging home O2, for example.) Same as the above example where the pt may be open to continuing home IV Abx if the team works with the pt. Or maybe there are less effective oral abx options they could Rx the pt instead. This changes the dynamic from an argument over a specific course of action and toward actually working with the patient to minimize the harm of the patient's suboptimal medical decision-making.

There's a good article advocating for the idea that the level of capacity required to leave AMA (return home) should be very low and that clinicians often overestimate the risk to that sort of plan.

 

[calvnandhobbs68]

Is the patient being physically held in the hospital/being prevented from leaving by security? Could she theoretically just stand up and walk out? What are her sats off of O2? Is she willing to work with the team to get home O2 set up? Does she have a baseline oxygen requirement related to the other comorbidities you mentioned? (COPD)

I'm agreeing with Barelby and splik at the moment. The current information provided indicates she likely has capacity. I suspect she's not in the dire straights that are being implied and team affect about covid denial and feeling that their efforts with the pt have been futile/frustrating are leading to a desire to punish the patient/enforce their "medical reality."

Make the case not about covid. A pt has a serious but not immediately life-threatening infection (but not something like active TB which would potentially require forced quarantining). The team thinks the patient stands a reasonable chance of dying in the next 1-2 weeks if the pt does not receive IV abx for another 5-10 days. The patient has been on abx for 3 days, they know they have an infection, they think it's getting better (it actually is getting better, with IV Abx), and they can wheel themselves out of the hospital. The patient initially presented for care at the advice of their family, went along with the first few days of hospitalization, and can reasonably be expected to be capable of the same choices after they leave the hospital. The team really wants the pt to stay inpatient to finish the abx and ensure the infection clears. The patient is antsy and categorically refuses the option of staying in the hospital for IV abx. IMO that pt has capacity and I've had plenty of pts leave AMA under such circumstances. Capacity is the default assumption until proven otherwise.

I touched on it earlier, but the team could be encouraged to take an approach where they assure the pt that the hospital is always ready to have her back if she needs their help and they do their best to support the pt's decision (help with arranging home O2, for example.) Same as the above example where the pt may be open to continuing home IV Abx if the team works with the pt. Or maybe there are less effective oral abx options they could Rx the pt instead. This changes the dynamic from an argument over a specific course of action and toward actually working with the patient to minimize the harm of the patient's suboptimal medical decision-making.

There's a good article advocating for the idea that the level of capacity required to leave AMA (return home) should be very low and that clinicians often overestimate the risk to that sort of plan.

Absolutely. It depends on how sick she actually is and if she can appreciate that or not. I've also encountered the same thing where a team just wants someone to be in the hospital for a few more days and they don't really want to be there anymore. Her level of functioning definitely matters. Is this a person who's just chilling out on 3L O2 that she may or may not need anyway and can get home O2 setup or is she dyspenic and desatting down to the 70s every time she tries to get out of bed on 3L O2 but continues to deny that she's sick at all? What kind of support does she have at home? Is the team just concerned that she might deteriorate or is there good reason to believe this would actually happen if she wasn't in the hospital? All those extra details and whether she understands those details matter.

I'll say that @splik comment of "It is unfortunate how poorly taught capacity evaluations are that so many psychiatrists do not appreciate this basic point" was rather annoying here. The reason this is a question that people are debating back and forth is because it isn't as clear cut as "no psych illness/mental disorder -> definitely have capacity even if they don't meet the appreciation standard". Not to mention the appreciation part is only one part of the capacity assessment. This stuff is basically law and ethics...it's all made up and based on philosophical/ethical theories of autonomy vs beneficence/nonmaleficence. It's not hard science.

 

[G Sheb]

I'm actually curious if 'substantial distortion of reality' is not a delusion. Of course you could argue that religious beliefs for example can be substantial distortions of reality and we don't argue they are delusions, but I do not think this is the case with covid conspiracy theories. They aren't religious or even cultural beliefs and this distinction here is important.

Shared psychosis is a thing, and so why is this belief not a delusion? Simply because it is shared by many other people? That does not cut it IMO.

I also think that people who are more prone to paranoia are the ones more likely to subscribe to those conspiracy theories. That tells us something about what we are dealing with.

 

[clozareal]

I'm surprised this topic hasn't come up earlier in the pandemic. I just wanted to say how much I've enjoyed reading and learning from this thread.

I wonder how the advent of online forums that allow people who have certain outlier ideas to more easily come together to develop into more solidified beliefs has affected our idea of delusions or not. There are lots of people on the schizophrenia spectrum that can come together to form a subculture. If that subculture endorses ideas that a majority of people disagree with, would that be deemed delusional if they are fixed and (according to that dominant group) false?

A couple of questions that I haven't seen answered directly:

• Is believing in QAnon a shared delusion or not?
• Is denying that COVID-19 is a real thing a delusion or not?

For the case above, I would have decided to let them leave AMA. There doesn't seem to be a durable change in mental status that would lead me to believe they had an underlying psychiatric condition, one that would have led them to make a different decision if they have not had said condition.

 

[michaelrack]

Is belief in Russia collusion a scared delusion?
And while elements of qanon belief is delusional (including that whole Kennedy thing), the core belief of childhood sexual abuse may yet turn out to be true

 

[WisNeuro]

Is belief in Russia collusion a scared delusion?
And while elements of qanon belief is delusional (including that whole Kennedy thing), the core belief of childhood sexual abuse may yet turn out to be true

Just to clarify, are you implying that there is indeed a world-wide cannibalistic, satanic, pedophilia cabal that international governments are colluding to cover up? Or, are you just really mad at Wayfair because they messed up an order or something?

 

[deleted1100659]

This is actually a great question that required me to look into both sides.

She has the ability to retain the information being spoken to her, she chooses to not acknowledge that information. I believe this is more of a choice, as it comes down to her political beliefs influence her decision making. There is nothing that is actively interfering with her ability to understand her diagnosis, her ignorance is a result of her own decisions, especially if shes fully coherent and functional in all other ways, mentally.

In a similiar way of how a jehova witness refuses a blood transfusion out of religious beliefs, to some people the politics of trump have become their religion. There is the ability to retain the information, weigh it, and do their own research about it, but despite this, they choose to ignore factual data. These are the same people who refuse to get vaccines, and we dont force vaccines on them, due to their ignorance and ability to act in their own best interest, because autonomy says that people should be given choices and allowed to make their choice, no matter how stupid that choice is, if they have the capability to understand the choice. I would argue that she might understand it, she just refuses to believe it. There is nothing interfering with her ability to understand it (based upon what ive read), she has made the choice to align her beliefs with conspiracy over facts.

I think in this scenario strong documentation comes into play, also maybe even holding a family meeting would be a great idea.

 

[michaelrack]

Just to clarify, are you implying that there is indeed a world-wide cannibalistic, satanic, pedophilia cabal that international governments are colluding to cover up? Or, are you just really mad at Wayfair because they messed up an order or something?

Definitely not cannibalism.
Yes on pedophilia cabal.
Satanic is a matter of interpretation. But I don't believe that all involved are worshipping Satan.
The boy scouts covered up pedophilia. My beloved Catholic church covered up pedophilia. I don't think it's psychotic to believe that international governments are covering it up (but I do acknowledge my belief could be erroneous). I don't think epstein committed suicide.

 

[deleted1100659]

Definitely not cannibalism.
Yes on pedophilia cabal.
Satanic is a matter of interpretation. But I don't believe that all involved are worshipping Satan.
The boy scouts covered up pedophilia. My beloved Catholic church covered up pedophilia. I don't think it's psychotic to believe that international governments are covering it up (but I do acknowledge my belief could be erroneous). I don't think epstein committed suicide.

pedophilia cabal? Like bill gates/the clintons/etc are all buying kids to abuse them?

 

[Mass Effect]

I suspect she's not in the dire straights that are being implied and team affect about covid denial and feeling that their efforts with the pt have been futile/frustrating are leading to a desire to punish the patient/enforce their "medical reality."

While I agree with most of your post, I think the above is unfair. I wasn't at the hospital on Saturday but I didn't get the sense that the team affect was leading to desire to punish the patient out of frustration or anything of the sort. I think there was genuine concern that if this individual did not believe in conspiracy theories, they would opt for care. This was a change from baseline in terms of their view toward healthcare professionals. So the question became as others on this thread have mentioned, are delusions such these where it's illogical and there's more than ample evidence it's untrue, a mental illness? And if yes, is it inhibiting her ability to grasp the seriousness of her condition?

Again though, I agree with your overall point. Autonomy is important and in someone with no other mental health issue, it'd be difficult to make the case she doesn't have capacity. I don't know the answer to the other questions you asked and given that the patient was sent home, I'm not inclined to ask my colleague at this point as the case was upsetting for everyone involved.

 

[Mass Effect]

I'm actually curious if 'substantial distortion of reality' is not a delusion. Of course you could argue that religious beliefs for example can be substantial distortions of reality and we don't argue they are delusions, but I do not think this is the case with covid conspiracy theories. They aren't religious or even cultural beliefs and this distinction here is important.

Shared psychosis is a thing, and so why is this belief not a delusion? Simply because it is shared by many other people? That does not cut it IMO.

I also think that people who are more prone to paranoia are the ones more likely to subscribe to those conspiracy theories. That tells us something about what we are dealing with.

I think this is the team's thinking too which I can't really argue with. Where is that line between an extreme overvalued belief and a shared delusion? Cults for example? At what point do we cross the line between an extreme belief and mental impairment?

 

[Mass Effect]

Definitely not cannibalism.
Yes on pedophilia cabal.
Satanic is a matter of interpretation. But I don't believe that all involved are worshipping Satan.
The boy scouts covered up pedophilia. My beloved Catholic church covered up pedophilia. I don't think it's psychotic to believe that international governments are covering it up (but I do acknowledge my belief could be erroneous). I don't think epstein committed suicide.

Jesus take the wheel.

 

[Candidate2017]

I guess my only pause if I were doing the eval would be that from the details involved, it's not entirely clear if she appreciates the risk of the pneumonia and how her health negatively interacts with that risk.

The majority of the public doesn't fully appreciate their illnesses or effects of their actions on their health.

The capacity bar is very low. To argue otherwise would mean locking up substance abusers, patients noncompliant with HTN meds, patients who no show their dialysis, patients who say "but only the Xanax works for my bipolar", patients who demand Z-packs, patients who are obese, patients who just want meds and refuse to partake in talk therapy etc.

Also, all physicians should be able to assess for medical capacity. It is not the singular domain of psychiatry, so most capacity consults are nonsense because the primary team merely wants psychiatry to convince the patient to comply with the treatment plan or for psychiatry to rubber stamp the team's decision to let the patient leave AMA and assume liability.

 

[Mass Effect]

The majority of the public doesn't fully appreciate their illnesses or effects of their actions on their health.

The capacity bar is very low. To argue otherwise would mean locking up substance abusers, patients noncompliant with HTN meds, patients who no show their dialysis, patients who say "but only the Xanax works for my bipolar", patients who demand Z-packs, patients who are obese, patients who just want meds and refuse to partake in talk therapy etc.

Also, all physicians should be able to assess for medical capacity. It is not the singular domain of psychiatry, so most capacity consults are nonsense because the primary team merely wants psychiatry to convince the patient to comply with the treatment plan or for psychiatry to rubber stamp the team's decision to let the patient leave AMA and assume liability.

Maybe but there are some capacity evals that are more nuanced like this one. I think it's completely appropriate to involve psych in cases like this.

 

[Candidate2017]

Just to clarify, are you implying that there is indeed a world-wide cannibalistic, satanic, pedophilia cabal that international governments are colluding to cover up? Or, are you just really mad at Wayfair because they messed up an order or something?

I have a number of patients who were abused by their Boy Scout leaders or priests. Epstein is the most high profile situation that highlights how small and well-connected the world of the rich and powerful are, but there is a long history of powerful people and organizations engaging in sex rings or covering up sex crimes.

 

[deleted1100659]

I have a number of patients who were abused by their Boy Scout leaders or priests. Epstein is the most high profile situation that highlights how small and well-connected the world of the rich and powerful are, but there is a long history of powerful people and organizations engaging in sex rings or covering up sex crimes.

I agree the rich and powerful most likely abuse their power and do sketchy stuff

But its my understanding the qanon theory is they abduct kids and harvest their adrenochrome or w/e its called, and ship them in wayfair containers. Thats slightly less believable.

 

[WisNeuro]

We went from capacity evals to full Qanon in this thread. That is...something. Who's going to go all Lindell and start spouting crack-addled theories about Hugo Chavez coming back from the dead to launch Jewish Space lasers?

 

[Mass Effect]

I agree the rich and powerful most likely abuse their power and do sketchy stuff

But its my understanding the qanon theory is they abduct kids and harvest their adrenochrome or w/e its called, and ship them in wayfair containers. Thats slightly less believable.

I mean, forget the outrageous stuff. Even the more paired down stuff is BS. Yes sex trafficking and child sexual abuse exists. Yes I'm sure there are more Epsteins out there and some already under fire (won't name names to avoid further political rebuttal). But this theory is based on the belief that a major political party is conspiring and colluding in grooming, abducting and trafficking children for this purpose and the leader on the opposite side of the aisle is the savior who will set all these children free. Let's not give it credence in a thread that isn't supposed to be about the sorry state of politics.

 

[Old&InTheWay]

I think there is an important distinction between the delusions that patients with schizophrenia or who are manic experience, and conspiracy theories, shared delusional beliefs, etc. that is not fully captured in the DSM. In the former, the delusion originates internally and is due to an abnormal affective state/experience and impaired reality testing. In the latter, the false belief originates externally and is caused by cognitive error. The DSM uses behavioral markers to define delusions as independent pathological symptoms, when delusions are probably better understood as a result of the true underlying pathological phenomenology (i.e. increased salience, apophany, etc.).

I also can't help but wonder whether the idea of "delusion as false belief" is outdated. In order for delusions to exist, we would need to live in a world where there exists a shared belief that there is indeed such a thing as objective fact. I'm not sure that that's the world we presently live in.

 

[Mass Effect]

I think there is an important distinction between the delusions that patients with schizophrenia or who are manic experience, and conspiracy theories, shared delusional beliefs, etc. that is not fully captured in the DSM. In the former, the delusion originates internally and is due to an abnormal affective state/experience and impaired reality testing. In the latter, the false belief originates externally and is caused by cognitive error.

Take that further. If the false belief originates externally and caused by cognitive error, does the end result, i.e. abnormal affective state/experience and impaired reality testing, make it any less harmful? Unless you suggest that isn't the end result? I think it is the result in many or most cases. Should we be anymore inclined to give this false belief credence or not consider it in issues related to capacity if the etiology is a shared external belief?

The DSM uses behavioral markers to define delusions as independent pathological symptoms, when delusions are probably better understood as a result of the true underlying pathological phenomenology (i.e. increased salience, apophany, etc.).

But why? I'd argue the behavioral markers predict the affect on one's life (and those around them) better.

 

[Old&InTheWay]

Take that further. If the false belief originates externally and caused by cognitive error, does the end result, i.e. abnormal affective state/experience and impaired reality testing, make it any less harmful? Unless you suggest that isn't the end result? I think it is the result in many or most cases. Should we be anymore inclined to give this false belief credence or not consider it in issues related to capacity if the etiology is a shared external belief?



But why? I'd argue the behavioral markers predict the affect on one's life (and those around them) better.

I don't think I communicated clearly above. I think the abnormal affective state and impaired reality testing is the root cause rather than the end result of true delusions. And I don't think that people who believe in false conspiracy theories develop impaired reality testing, or an increased sense of salience, etc. However they may as a group be more prone to jumping to conclusions (and I believe there's some research to back this up).

Perhaps a reasonable analogy is the idea of "sadness." It could be due to an underlying biochemical depression, or it could be the result of having suffered a recent loss. Behaviorally, the sadness may appear the same in both cases and may cause the same amount of distress in the moment. However, in the former, the sadness is not serving any beneficial purpose to the patient, whereas in the latter, sadness may facilitate the processing of grief and loss.

Perhaps one could argue that someone who holds a false belief due to cognitive error has the potential to learn from their mistake, which may actually be beneficial to the individual in the long run.

I don't have all these ideas fully fleshed out, mostly just thinking out loud here.

 

[Mass Effect]

I don't think I communicated clearly above. I think the abnormal affective state and impaired reality testing is the root cause rather than the end result of true delusions. And I don't think that people who believe in false conspiracy theories develop impaired reality testing, or an increased sense of salience, etc. However they may as a group be more prone to jumping to conclusions (and I believe there's some research to back this up).

Perhaps a reasonable analogy is the idea of "sadness." It could be due to an underlying biochemical depression, or it could be the result of having suffered a recent loss. Behaviorally, the sadness may appear the same in both cases and may cause the same amount of distress in the moment. However, in the former, the sadness is not serving any beneficial purpose to the patient, whereas in the latter, sadness may facilitate the processing of grief and loss.

Perhaps one could argue that someone who holds a false belief due to cognitive error has the potential to learn from their mistake, which may actually be beneficial to the individual in the long run.

I don't have all these ideas fully fleshed out, mostly just thinking out loud here.

Lets suppose all of those things. And lets go with learning from mistakes. That's fine if we're talking about the lifespan who has a shared false belief. But as psychiatrists, our moment of impact in capacity evaluations is one moment in time and that one moment happens to be where the patient could be in a life and death situation.

Put this case aside and lets consider what you said about sadness due to loss. You are correct that it could be helping to facilitate the processing of grief and loss. But does that mean the impairment they *may* suffer would be different from sadness that's the result of biochemical depression? If you saw two patients in the hospital who both wanted to leave AMA and had the exact same answers to the questions on a capacity eval (I recognize this would never happen), would you be more willing to keep the depressive sadness over the grief sadness and if so, why if the end result of leaving AMA is the same (assuming same level of recognition of illness or not, ability to reason or not, etc)?

 

[nexus73]

It does sound like it's a bad decision rooted in ideology. Not believing the doctors, because she doesn't trust them because they're just diagnosing everything as COVID.

I've seen something similar come up in competency to stand trial evaluations in people who believe they are sovereign citizens. They reject the authority of the police, court, prosecutors, for a variety of made up reasons usually hinging on some misinterpretation of the Magna Carta or Maritime law or old legal dictionaries from 100 years ago. They refuse to work with attorneys because they imagine they can pull out all this legal nonsense and get themselves out of the charges, and when their defense attorney advises them against it they fire them. Of course, these people are NOT delusional. They just believe in this false ideology, almost like a religion. No antipsychotic is going to fix it. So you've ultimately just gotta let them go to court and likely get destroyed by their own bad decisions. It's kind of like Wesley Snipes believing he didn't have to pay taxes because of some misinterpretation of the IRS being an illegitimate government agency. Snipes wasn't delusional, he just really didn't want to pay his taxes and was willing to let himself be taken in by a similar ideology.

This woman wants to believe COVID is fake so strongly that she's willing to risk her own life.

 

[deleted1100659]

It does sound like it's a bad decision rooted in ideology. Not believing the doctors, because she doesn't trust them because they're just diagnosing everything as COVID.

I've seen something similar come up in competency to stand trial evaluations in people who believe they are sovereign citizens. They reject the authority of the police, court, prosecutors, for a variety of made up reasons usually hinging on some misinterpretation of the Magna Carta or Maritime law or old legal dictionaries from 100 years ago. They refuse to work with attorneys because they imagine they can pull out all this legal nonsense and get themselves out of the charges, and when their defense attorney advises them against it they fire them. Of course, these people are NOT delusional. They just believe in this false ideology, almost like a religion. No antipsychotic is going to fix it. So you've ultimately just gotta let them go to court and likely get destroyed by their own bad decisions. It's kind of like Wesley Snipes believing he didn't have to pay taxes because of some misinterpretation of the IRS being an illegitimate government agency. Snipes wasn't delusional, he just really didn't want to pay his taxes and was willing to let himself be taken in by a similar ideology.

This woman wants to believe COVID is fake so strongly that she's willing to risk her own life.

to sum it up: they're a lot of stupid people in the world, but perhaps that is their god given right.

 

[WisNeuro]

to sum it up: they're a lot of stupid people in the world, but perhaps that is their god given right.

I don't worry as much about rights given by imaginary friends, I'm more concerned about rights given according to state and federal statutes and minimizing my liability. Personally, I'm all about letting these *****s die at home and freeing up beds, professionally, I'll CYA the best I can.

 

[sloop]

Does not have capacity.

One of the interesting things about capacity, and one of the reasons why people say that it’s not exclusively an issue for psychiatrists, is that someone having capacity or not is agnostic to the cause of the incapacity.

In contrast to something like competence to stand trial, where there is generally a statutory requirement that the deficits be due to “mental disease or defect” or similar language, capacity is a clinical determination and does not have such restrictions. It is entirely possible that a non-demented, non-delirious person without a psychiatric illness nonetheless lacks capacity for a particular decision based on their inability to understand and rationally appraise the relevant information. That is what is happening here.

The attending is wrong about how he is considering the politics here. First of all, it seems speculative to state that this person’s issues with understanding their situation relate primarily to politics. It also doesn’t actually matter if that’s the case. If someone told me that they were refusing a blood transfusion because they’re a Democrat, and that’s all they can say to explain their decision, thats not rational. Similarly, if someone fundamentally rejects the facts related to their medical circumstances because of a conspiracy theory, they do not actually understand their medical circumstances.