Indications for Psychiatric Capacity Evaluation in Patients Requesting to Leave Against Medical Advice
Psychiatric consultation for capacity evaluation should be requested when a patient requesting to leave AMA shows signs of impaired decision-making ability due to potential psychiatric illness, cognitive impairment, or when their decision poses significant risk to their health and safety.
Understanding Capacity Assessment
Capacity is the foundation of informed consent and requires that patients demonstrate:
- Understanding of their medical situation
- Appreciation of the consequences of their decision
- Reasoning in their thought process
- Ability to communicate their wishes 1
Key Indications for Psychiatric Capacity Evaluation
1. Cognitive Impairment
- MMSE score below 24 (highly sensitive) or below 21 (highly specific) for identifying patients without capacity 2
- Signs of delirium, dementia, or other cognitive disorders (most common psychiatric diagnoses in capacity cases) 2
- Impaired ability to understand or retain medical information
2. Psychiatric Symptoms Affecting Judgment
- Active psychosis with delusions affecting medical decision-making
- Severe depression with hopelessness affecting treatment decisions
- Severe anxiety interfering with rational decision-making
- Suicidal ideation or intent 3
- Manic symptoms with poor impulse control
3. High-Risk Situations
- Patient's decision to leave poses immediate risk of death or serious harm 4
- Refusal of clearly beneficial recommended treatment 1
- Patient readily agreeing to leave despite obvious serious medical risks 1
- Concern that patient may harm themselves or others after discharge
4. Inconsistent Decision-Making
- Fluctuating mental status or level of consciousness
- Inconsistent reasoning about decision to leave
- Inability to articulate reasons for leaving that align with stated values
5. Legal and Ethical Considerations
- When there's uncertainty about whether the patient has decision-making capacity or mental illness and failure to detain may lead to serious harm 4
- When patients threaten to leave AMA and/or refuse treatments or procedures (representing 64% of capacity consultation requests) 5
Assessment Approach
When evaluating capacity in patients requesting to leave AMA:
Assess mental status thoroughly, including:
Evaluate understanding of medical situation:
- Patient's comprehension of their condition
- Understanding of risks of leaving AMA
- Appreciation of benefits of continued treatment
Document risk assessment:
Important Considerations
- Capacity is decision-specific and time-specific – a patient may have capacity for some decisions but not others 3
- Patients cannot be treated as lacking capacity merely because they make an unwise decision 3
- Refusal of treatment by an adult with capacity is legally binding, even if refusal is likely to result in the patient's death 3
- Primary medical teams tend to be more accurate when they determine patients lack capacity than when they believe patients have capacity 2
When Capacity Is Lacking
If a patient is determined to lack capacity:
- Identify a surrogate decision-maker 1
- Consider emergency care without formal consent if delay would increase risk of death or serious harm 1
- Consider involuntary treatment if criteria for mental health commitment are met
- Document the rationale for treatment decisions thoroughly 3
Psychiatric consultation for capacity evaluation is a valuable tool that can resolve approximately 88% of cases where patients threaten to leave AMA or refuse treatment 5, making it an essential resource in managing these challenging clinical situations.