Whenever a patient visits the doctor’s office, there is always an idealized hope that the patient and physician will work together to come up with a treatment plan. Part of the management of disease involves making sure the patient understands the risks and benefits of a particular therapy. In order to do so, patients must have capacity to understand what treatment entails. The patient may refuse any treatment for any reason, so long as he has the capacity to understand what the risks are when refusing treatment. For example, a Jehovah’s Witness could refuse to take a blood transfusion even when his anemia is so bad that he could die from poor oxygen perfusion. Similarly, any adult can fill out a Do Not Resuscitate order with the understanding that if he should have a heart attack and suffer cardiac arrest, no one will come to his aid.
In psychiatry, however, many of our patients lack capacity. One might be so psychotic that he does not understand his negligence may cause harm to himself or others. Psychiatrists are constantly asked to determine a patient’s ability to understand treatment decisions. Sometimes, a person might be forcefully admitted to a hospital for treatment if his mind is so disorganized as to cause immediate, life-endangering health problems. Psychiatrists can hold a patient in a hospital for a given number of days to provide treatment for medical or psychiatric illness. During this time period the patient has the right to legal representation and may petition a court seeking discharge from the hospital.
Today, I got to sit in on a court hearing for a patient to was so psychotic that he did not notice that the cellulitis on his legs had become necrotic. In my state, the district attorney’s office serves as the hospital’s legal representative to keep the patient involuntarily committed for treatment. The public defender’s office represents the patient. Our attending began giving a summary of the patient’s hospital stay over the previous week. He mentioned that the patient has been washing his face in the toilet, shouting racial slurs, making sexually inappropriate comments about nurses, and talking about the fourth Reich. At this point the patient then began doing the Nazi salute and stated, “Black people are dangerous.” When the defense attorney began questioning the patient, the conversation with something like this:
Attorney: I understand that you are a veteran. Are you willing to take treatment at the VA?
Patient: They are all robots there. I would kill every one of them.
Attorney: Do you want to stay here in the hospital? And if so, how long?
Patient: I want to stay here for 60 years.
Attorney: Do you understand that you are sitting in front of a judge and have the chance to be discharged from the hospital? Now I’m going to ask you again, how long do you want to stay in this hospital?
Patient: 60 years!
Attorney: What do you plan to do once you’re discharged from the hospital?
Patient: I want to go to the South hospital for six years.
I was pretty sure that our side was going to win the verdict when the judge began laughing.