They're Gassing My Room
This is the therapeutic stance toward a fixed persecutory belief that neither collludes with nor directly confronts the delusion
What is aligning with the affect/goal rather than debating the content?
Direct confrontation of a fixed delusion ruines the therapeutic relationship and tends to make those beliefs stronger. However, validating the patient's emotional experience, without justifying their delusion, is what builds alliance in paranoid patients, and increased attention to the patient-physician relationship is warranted when the patient is prone to ruminations about others' intentions. This is something I was able to truly appreciate when working with Dr. D on Mr. H and his requirements/fears on going back to his nursing home.
Managing acute withdrawal is necessary but insufficient; this is the treatment gap the CL consultant should close before discharge.
What is initiating anticraving pharmacotherapy for alcohol use disorder?
Detox alone is not enough for AUD. The APA and VA/DoD guidelines frame *naltrexone, acamprosate*, disulfiram, topiramate, and gabapentin as the maintenance top choice— and the inpatient consult is often the highest-yield moment to start oneto facilitate this process post detox.
He was placed on an involuntary hold for this acute, clearly beneficial-to-treat medical problem.
What is acute kidney injury from obstructive uropathy?
The hold hinges on a medical emergency his psychiatric illness prevents him from appreciating, not on the psychiatric condition alone. Prompt, complete bladder decompression is the initial management***
Paper: APA Resource Document on Decisional Capacity Determinations in Consultation-Liaison Psychiatry, Bourgeois et al., 2019
These are the four components of the Appelbaum & Grisso capacity model.
What are understanding, appreciation, reasoning, and communicating a choice?
This was something that I hadn't actively seen in practice much during my other rotations however was highlighted in different ways during this rotation. Particularly with the two cases that I was able to see of Mr. H with paranoid delusions and Mr. H #2 with schizophrenia, I was able to see examples of both absence of reasoning and understanding in two case scenarios and what that entails when it comes to making medical care decisions (one was reasoned with enough for voluntary admission and the other certed in order to receive proper medical treatment)
This negotiated antipsychotic strategy let the patient accept escalation of care without feeling coerced.
What is uptitrated LAI aripiprazole with an oral aripiprazole 5 mg bridge?
The "give" of agreeing to stay voluntarily on the inpatient unit and keeping the format he already tolerated (the LAI) bought the "take" which was a therapeutic dose increase. According to a systemic review "LAIs for maintenance treatment of bipolar disorder and schizoaffective disorders" by Puranen et. al, in schizoaffective disorder, LAIs and antipsychotic + mood-stabilizer combinations carry the strongest real-world evidence for reducing psychosis rehospitalization by 16-24% vs antipsychotic monotherapy, making the LAI both an alliance tool and an evidence-based choice in our case with this patient.
This anticonvulsant reduces drinking and craving, is VA/DoD firstline, and doubles as a tool in the patient with comorbid PTSD or obesity
What is topiramate?
Honestly had forgotten that this was even an off label option prior to this service since it was rarely used during my time on psych consults at Loyola. While reading up on this, I found that this could be especially useful for those who have comorbid PTSD as well and as I saw a lot at Hines, PTSD and alcohol use were always hand in hand. The dosing is started around 25-50 mg daily and is especially contraindicated in prior metabolic acidosis, nephrolithiasis/renal impairment, or narrow-angle glaucoma.
This ethics principle justifies overriding his refusal, and this is the principle it is being weighed against.
What are beneficence versus autonomy?
This case really showed me the tension between beneficence and autonomy
While reading up on this, I found that there are formal guidelines that exist to confirm benefit outweighs the autonomy interest before treating over objection. The VA/DoD schizophrenia clinical practice guidelines actually documents this which I found to be really interesting stating, "too great an emphasis on autonomy can cost lives, and clinicians are obliged to prioritize preventing harm when illness impairs judgment." I feel like this truly embodies this patient's case scenario and the judgement call that was taken at the end of the day.
This is the most common reason for decisonal incapacity.
What is neurocognitive disorder?
Something that I appreciated the paper highlighting is that more than any other reason, usually, delirum vs dementia is playing a role in the decisional capacity of a patient, especially one who is of older age. The paper had stats showing that most common psychiatric diagnoses contributing to incapacity were cognitive disorders (54.1%), substance use disorders (37.2%), and psychotic disorders (25%). Saying this, one of the key things I took away from this section of the paper is to always always always do a MMSE or MoCA on these patients in this case scenario to get a feel of the severity of the dementia/delirium and how it can be impacting their decisions. While this is something that seemed obvious to me for a daily consult on a delirious patient, when it came to an older patient who was having their decisional making capacity checked, these examinations mainly fell through the cracks on my end so it was a good reminder
With active melena, these are the valproate-specific labs to check before adjusting the Depakote 1500 mg/day.
What are a valproate level, CBC (thrombocytopenia), and LFTs (± ammonia)?
From my third time experience on C/L psychiatry, valproate-associated thrombocytopenia and platelet dysfunction are a clean example of the psychotropic-medical side effect/complication a CL consultant is expected to catch and should always be conveyed to the primary team that the mood stabilizer may be destabilizing his GI bleed and would potentially need to be lowered in dosage/put on temporary hold. A classic bread and butter example of things to catch while working on a medically active psychiatry patient.
Head-to-head, this drug has the larger effect on drinks-per drinking-day and heavy-drinking days, while this one has the better safety/monitoring profile
What is topiramate versus gabapentin?
Something to always keep in mind when choosing a medication is the safety profile and the risk vs benefit for a patient. When comparing these two off-label drugs used for AUD, I found a meta-analysis that showed that topiramate showed moderate-strength benefit on percentage of heavy-drinking days and drinks per drinking day, whereas gabapentin's evidence was lower-strength but much more safe with significantly less contraindications and need for monitoring. So, when considering these two options, the choice is individualized to comorbidity, misuse risk, and tolerability.
This is the paradox at the heart of the case: he has done this for himself for years, which is exactly what makes the override ethically hard.
What is that his self-preservation (surviving homeless, avoiding care but getting when necessary) argues he has some functional capacity, even as he denies having any medical problem?
The uncomfortable part that was seen in this case was not that he is incapable of seeking help, it is that he has demonstrably kept himself alive, so the team must justify why THIS decision, at THIS risk level, exceeds his capacity to refuse. Illness denial is the specific key in this case, not his lifestyle or his diagnosis that ultimately led to his inpatient hospitalization cert for medical care, something I have never seen before. The refusal is overridden not because he is psychotic or unconventional, but because a demonstrable deficit impairs THIS decision while the harm is grave and imminent
These are the types of disorders that were studied and seen to have a psychopathology correlation with impaired Decisional Capacity that was much lower than correlations between overall poor cognitive performance and impaired Decisional Capacity.
What are psychotic disorders?
It was interesting to find this out while reading because it seems to be a common misconception that having a psychotic disorder directly and obviously affects someones decision making capacity but when studied, this is clearly not the case. I found this to be very true and relatable to Mr. H#2's case and how it must be an implicit bias to jump to conclusions regarding the impact a psychiatric illness, which tends to be severe, has on one's ability to understand, synthesize information and then convey their opinions regarding a treatment.
Name the core CL skill this case teaches (conceding on lower-stakes points to secure the highstakes goal)
What is the therapeutic give-and-take?
Meeting the patient where he was (amenable voluntary inpatient transfer, a familiar medication regimen with conveyed alterations, and delaying disposition) kept him engaged and safe while his psychosis was treated to potentially alleviate future problems. This approach showed me the importance of shared decision-making no matter what the patient's condition is as well as having a specific finesse when communicating with the patient what you would like their course to look like and if it's agreeable with them.
This is the practical reason the acute detox admission is the ideal window to start anticraving therapy.
What is the patient is stuck and has no choice but to listen?
Beyond danger to self/others, this third commitment standard fits a patient who cannot meet basic needs including medical care.
What is grave disability?
Most certifications I have seen filled out during my time on C/L had always been for the patient being an immediate harm to self or others and have not needed further indications however, with this case, I was able to see the other possible reasons that can be marked and the nuances with each option. For this case scenario, the indication we had marked off was the second which was "A person with mental illness who, because of his or her illness is unable to provide for his or her basic physical needs so as to guard himself or herself from serious harm, without the assistance of family or others, unless treated on an inpatient basis" rather than the third which is "A person with mental illness who: refuses treatment or is not adhering adequately to prescribed treatment; because of the nature of his or her illness is unable to understand his or her need for treatment; and if not treated on an inpatient basis, is reasonably expected based on his or her behavioral history, to suffer mental or emotional deterioration" the last of which we decided to not go with because of the the last portion (to suffer mental or emotional deterioration). While none of the options felt exactly right regarding the necessity for our patient's involuntary admission, it made me realize the nuance to the form and the consideration you must have when considering the indication but also to remember you are capturing a snapshot in time for this patient and dose not mean whatever you pick has to necessarily consistently be true regarding the patient.
This is something you can use to help supplement your clinical assessment of someone's decisional making capacity
What is DC specific instruments?
I wasn't aware that there are instruments/assessments out there that help with facilitating your clinical assessment/judgement on a patient.
-they allow for a more standaridized approach but are not essential
-one is not considered the gold standard as certain ones may assess certain domains more than others
-allow for separation in evaluation of the different domains systematically
-used more in research settings rather than clinical
-Examples:
-Aid to Capacity Evaluation (ACE): A practical, widely validated 8-item clinician tool tailored to the specific medical decision under review.
-MacArthur Competence Assessment Tool for Treatment (MacCAT-T): A semi-structured clinical interview that scores understanding, appreciation, and reasoning
-Hopkins Competency Assessment Test (HCAT): A brief screening tool focused primarily on a patient's understanding of medical treatment rights and choices