An Introduction to Psychiatry
Consultation Liaison Service
Bikash Sharma, MD
PGY: III
06/ 21/ 2011
Learning Objectives
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Role of Consultation Liaison (CL) in Inpatient
Hospital setting/ (Emergency Room)
- Consultation Psychiatrist as effective physician
- The art of Psychiatric consultation
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Diversities of cases encountered in CL service
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Informed Consent
Capacity and Competency
Capacity evaluation
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Consultation Psychiatrist as
effective physician
The essence of effective consultation in any
medical specialty lies in the expert knowledge
and skill that the invited consultant brings to the
bedside.
If the process is to work, both the consultee and
the consultant must believe this.
The alternative is at best a waste of time and, at
worst, a fraud perpetrated on the patient in
which the best of intentions accomplish nothing
Kontos N et al 2003
Art of psychiatric consultation
Clinical Approach
 Environmental influences
 Style of interaction
 Use of language
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Clinical Approach
Do:
Think
Physiologically
Existentially
 Avoid
Distortion of truth
An Ulterior motives
Illicit activity
Immoral activity
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George B Murray, S.J, M.D
Do Not Do:
Do not take low
 Do not tie your self esteem to the team’s
adoption of your recommendations
 Do not feel the need to make a diagnosis
on day one
 Do not say everything you have to say one
day one
 Do not practice checklist psychiatry
 Do not predict the future
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Consultative Process
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Speak with the referring physician
Review current and past records
Review medications
Gather collateral data
Examine the patient
Formulate diagnosis and recommendations
Write a note
Speak with the referring physician
Role Play
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Specific reason for consult
Triage
Mental status
Informed consent including patient’s willingness/
awareness to talk to psychiatrist
Detailed Past/ Present medical/ psychiatric
information
Collateral information
Recommendation to the primary team directly
Follow up
Differential Diagnosis
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Medical
Psychiatric presentation of medical conditions
Psychological reactions to medical conditions
Psychiatric complications of medical conditions
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Psychiatric
Medical presentation of psychiatric conditions
Co morbid medical and psychiatric conditions
Medical complications of psychiatric conditions
Informed consent
1. Salgo Vs. Leland Stanford Junior
University Board of Trustee (1957)Informed Consent
2. Natanson Vs. Kline ( 1960)- Professional
Standard
3. Canterbury Vs. Spence- WDC (1970) &
Cobbs Vs. Grant- CA ( 1970)- Patient
Orientated Approach
3 Elements in treatment decision
making, ie:Informed Consent
“Disclosure of Information within a context
that allows voluntary choice made by a
patient who is competent to decide”
Adequate information > Mental Capacity>
Informed Consent
Valid Informed Consent
Permission voluntary given by a competent person
without any elements of force, deceit, coercion
after explanation and disclosure of
1. Purpose and details of procedure or treatment
2. Risks, Benefits and available alternative
treatment/s
3. The right to withdrawal consent verbally or in
written forms at anytime
Exceptions
Life threatening situation
 Patient who waive their rights to disclose
and consent (do not want to be informed)
 Instances where “ disclosure’ may be
harmful to the patient “ Therapeutic
privileges”
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Capacity vs. Competency
Clinical vs. Legal term that denotes the ability to
make rational and reasonably well informed
decisions by a particular patient (vs. person) in
their treatment and/ or life decision/s
 Capacity is a clinical determination that
addresses the integrity of mental functions.
 Competency is a legal determination that
addresses societal interest in restricting a
person’s right to make decisions or do acts
because of incapacity.
Case Scenario
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Primary clinician simultaneously assess comprehension of a patient
to what has been discussed about an illness, workups, procedures
If there is a concern that patient does not seem to understand
contents of discussion to a reasonable degree
Capacity to informed consent?
CL consult for capacity to make “ particular” decision
If Primary team and CL both agree that a patient lacks minimal
capacity to consent, then patient is considered “incapacitated” to
make decision in that “ particular’ area
Alternate decision maker sought out (If not emergency: Health care
Proxy Vs. Health care Surrogate/ Living will and advanced
directives. If emergency: Emergency Temporary Guardian (ETG)
until the court determine that pt being incompetent; then a “ legal
guardian” is designated who takes decision for the patient in the
area specified by the court.)
Questions
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If a patient agrees with a procedure or treatment
recommended by clinician, then the question of capacity
is null, and patient is considered capacitated?
If a patient disagrees with a procedure or treatment
recommended by clinician, then the question of capacity
arises, and patient is considered incapacitated?
If a patient is incapacitated for treatment of HIV (medical
decision) , then patient is incapacitated for consenting to
other treatments ( other major life decision/s)?
What is threshold for Capacity?
STEPS IN DETERMINING A CAPACITY TO GIVE
INFORMED CONSENT TO HIS/ HER TREATMENT PLAN
I. Mental Capacity Assessment
II. Self disclosure
Being mentally ill doesn’t in itself imply a
loss of capacity or competency.
 Having Capacity or being Competent until
proven otherwise.
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I. Capacity Assessment
To have capacity to consent to “treatment”, 4 criteria
must be satisfied in a patient:
1.
2.
3.
4.
To understand relevant information about the PROPOSED treatment/
treatment OPTIONS/ NO treatment
Able to communicate a choice consistently
To appreciate own clinical situation (insight) with regard to the proposed
treatment (if a patient is in denial of illness, s/he will not be considered
competent)
To rationally manipulate (reasonable; sensible; sound judgment)
provided information/s
Process of Periodical Reassessment and Documentation
Steps in Mental Capacity
Assessment
A.
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General perspective or specific (Psychiatric hospitalization, ECT)
Find out the best language of communication
Determine if patient has adequate information on which to base a decision
MMSE: attention, concentration, memory
Inform the patient about the nature of the disorder, AND the risk and benefit of the
PROPOSED treatment, and of ALTERNATIVE treatments or of NO treatment
B.
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Repeat information number of times and in different ways.
Let the patient paraphrase or restate the understanding.
Evaluate nature of questions that patient asks regarding treatment plan
Periodical Reassessment of capacity ( if any change in clinical conditions or,
mental status such as in delirium or any modifications in treatment plan)
C.
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If patient has “severe deficit” in understanding information- No Capacity to make
informed consent or make decision Arrange a process for “ a substitute
decision maker”
II. Self disclosure
A. Consider the fact that patients will not disclose their thoughts
and emotions
 Stigma towards mental illness
 Fear of legal consequences
 Fear of hospitalization or prolongation of hospitalization or limitation
of privileges
 Psychiatrist as Omniscient:
- can reliably predict the most unpredictable human behavior
- can read mind
- “Lie detector”
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Common misconceptions towards skills of mental health
professionals: an uncertain treatment outcome
II. Self disclosure
B. Acknowledge the uncertainty of treatment
 Explain DIRECTLY to the patient that the clinician MUST rely on
patient’s self discloser in order to be of most help.
 Explain and ask explicitly to the patient the risk in withholding and
benefit in providing information
 For those who do not understand the importance of reporting
potentially dangerous thoughts or emotions or unable to report for
whatever reason (including denial of illness) will require more
conservative management.
 For those who sufficiently understand the significance of reporting
their dangerous thoughts or emotions, DOCUMENT it.( if patient
later elect not to report and consequently engage in self- injury, this
DOCUMENTATION will reveal that the patient understood the risk of
withholding information and that the decision not to seek help was a
deliberate (VOLUNTARY) and RATIONAL choice (Gutheil TG et al.
Bulletin of American Academy of Psychiatry and the Law, 1986).
The fundamental issue is whether the
person can be held accountable for the
consequences of his or her decisions and
actions.
Physician liability for suicidal
patient
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The psychiatrist’s goal is to identify those
individual who can “follow an agreed upon
treatment plan as well as need for reporting any
potentially dangerous thoughts or feelings BUT
then later may choose not to as a result of being
too sick, depressed, hopeless, psychotic.”
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“Stronger the therapist’s documented grounds
for finding the patient competent and thus able
to act TRULY voluntarily, the more remote the
prospect of malpractice liability is likely to be”
(Law at Massachusetts Mental Health)
Suicide Assessment:
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To predict the most unpredictable and the
most rear event of another individual.
Suicide Assessment
Dr. Barnes
 Psychiatric emergencies
Dr. Bland
 Management of Acute Agitation
Dr. Khurshid
 Involuntary Commitment
Dr. Malik
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