Background: A patient can be medically admitted to the hospital over their objection if they lack the capacity to refuse admission. Any treatment or intervention over a patient’s objection can be emotionally distressing and impact their future interactions with the healthcare system, including willingness to seek care. A patient has capacity for a medical decision if they are able to communicate a choice, demonstrate understanding of the situation, appreciate the impact of their choice, and demonstrate a rational thought process. In the emergency department (ED), capacity assessment is limited by patients’ brief lengths of stay and lack of longitudinal relationships with their teams. While all physicians can assess capacity, there are circumstances when psychiatric consultation can assist not only with assessment but also identifying factors contributing to patients’ lack of capacity, counseling regarding expectations, and providing recommendations for maintaining patient safety. In this poster, we review two cases of patients admitted for medical workup over their objection. Results: Both cases reviewed involve adults over age 75 with minimal formal psychiatric history who demonstrated paranoia and other factors interfering with their ability to understand their medical situations. In both cases, psychiatry was consulted following over 12 hours in the hospital (including the ED). They both received intramuscular injections of antipsychotic medications while resisting transfer to the medical unit. Ultimately, both patients underwent workup in the hospital voluntarily. Conclusion: Literature regarding capacity assessment in EDs is limited. In these two cases, psychiatric consultation earlier-on may have elucidated specific barriers to the patients’ understanding of their medical conditions and reasons for admission. The psychiatry team can also assist with conversations related to expectation-setting, including the possibility of being kept in the hospital over objection. In patients who may require interventions for their safety, the psychiatry team can provide recommendations. Considering psychiatric consultation when a patient’s capacity to make a specific medical decision is in question, particularly for psychiatric reasons such as paranoia, is appropriate and could improve patients’ overall experiences. Not explored here but also worth investigating are the unique ethical considerations posed by admission for workup over objection, given the logistics of pursuing medical workup for a patient who is resisting.
Learning Objectives:
Identify opportunities for psychiatric consultation related to capacity in the emergency department
Understand reasons for counseling patients regarding next steps in care
Explore challenges related to capacity assessment specific to ED settings
