Involuntary hospitalization of medical patients who lack decisional capacity: an unresolved issue.

Received August 23, 2005; revised January 18, 2006; accepted January 27, 2006. From the Dept. of Psychiatry, Univ. of Massachusetts Medical School. Address correspondence and reprint requests to Dr. Byatt, Dept. of Psychiatry, Univ. of Massachusetts Medical School, 55 Lake Ave North, Worcester, MA 01655. e-mail: [email protected] Copyright 2006 The Academy of Psychosomatic Medicine Psychosomatic-medicine psychiatrists often see patients on medical wards who lack the capacity to make treatment decisions when their refusal of necessary treatment may put their health at risk. Although civil commitment because of mental illness and/or being dangerous has been a statutorily regulated and well-studied practice in general psychiatry, there is currently a dearth of information about the issue of involuntary hospitalization for medical patients seen in consultation–liaison psychiatry whose medical disorders may either transiently or more chronically affect their mental status, leading to psychosis, confusional states, and impaired judgment. Consultation–liaison psychiatrists often struggle with problems presented by patients who lack decisional capacity secondary to a medical illness, are not verbally threatening to self or others, and want to leave the hospital against medical advice. Such patients at times have personality changes secondary to a general medical condition or delirium secondary to a general medical condition, but in particular jurisdictions may not meet the criteria or be appropriate for commitment to a psychiatric facility. Consultation–liaison psychiatrists are often consulted on such cases where the patient repeatedly attempts to leave against medical advice and may be combative and require restraints. This was precisely the dilemma captured in the following case of “Ms. S.” In this report, specific information about the case has been modified in order to deidentify the details of the case, yet the clinical factors remain illustrative of the difficulties that consultation–liaison psychiatrists often encounter.