Decision-Making in the Hospital Decision-Making in the Hospital Setting: Holds, Capacity, and Setting: Holds, Capacity, and

ConservatorshipConservatorship

J. Jewel Shim, MDJ. Jewel Shim, MD

Director, Psychiatry Consultation and Liaison ServiceDirector, Psychiatry Consultation and Liaison Service

UCSF Medical CenterUCSF Medical Center

ObjectivesObjectives

Review psychiatric holdsReview psychiatric holds Differentiate between competence and Differentiate between competence and

capacitycapacity Understand the four elements of capacityUnderstand the four elements of capacity Discuss issues with capacity in special Discuss issues with capacity in special

populationspopulations Know the two kinds of conservatorshipKnow the two kinds of conservatorship

IntroductionIntroduction

Medical decision making is a constant occurrence in Medical decision making is a constant occurrence in acute-care hospitalsacute-care hospitals

At times, physicians must balance what unfortunately At times, physicians must balance what unfortunately become competing interests; caring for patients and become competing interests; caring for patients and preserving life while upholding patients’ rights of preserving life while upholding patients’ rights of self-determination and autonomy to make healthcare self-determination and autonomy to make healthcare decisionsdecisions

It is important for physicians to be knowledgeable It is important for physicians to be knowledgeable about key issues related to decision making in the about key issues related to decision making in the hospital settinghospital setting

Psychiatric HoldsPsychiatric Holds

What is the appropriate next step when a What is the appropriate next step when a patient wants to leave AMA?patient wants to leave AMA?

a.a. Call securityCall securityb.b. Call the patient’s familyCall the patient’s familyc.c. Call a psych consultCall a psych consultd. d. Evaluate the patient’s capacity to Evaluate the patient’s capacity to determine his/her dispositiondetermine his/her disposition

Who can place a 5150?Who can place a 5150?

a.a. police officerpolice officerb.b. psychiatristpsychiatristc.c. neurologistneurologistd.d. social workersocial workere.e. any attending physicianany attending physician

Once on a 5150, a patient can be treated Once on a 5150, a patient can be treated even though he/she refuses treatmenteven though he/she refuses treatment

a.a. TrueTrueb.b. FalseFalse

Psychiatric holds clarifiedPsychiatric holds clarified

5150/72 hour hold5150/72 hour hold Based on at least one of 3 criteria defined by LPS ActBased on at least one of 3 criteria defined by LPS Act

• Danger to selfDanger to self

• Danger to othersDanger to others

• Grave disability (food, clothing, shelter)Grave disability (food, clothing, shelter) Can be used to hold patients in the hospital against Can be used to hold patients in the hospital against

their will their will (UCSF Parnassus)(UCSF Parnassus)• It must be demonstrated that the patient lacks capacity to decide It must be demonstrated that the patient lacks capacity to decide

their dispositiontheir disposition

• Failure to care for one’s bodily integrity can be included under Failure to care for one’s bodily integrity can be included under “grave disability” not “danger to self”“grave disability” not “danger to self”

• Does not allow patients to be treated against their willDoes not allow patients to be treated against their will

Psychiatric holds (cont)Psychiatric holds (cont)

5150 (cont)5150 (cont) Can be placed by a police officer, psychiatrist, or other Can be placed by a police officer, psychiatrist, or other

clinician that has specific training/credentialsclinician that has specific training/credentials Hold must be dated and timedHold must be dated and timed

• If there is an ED hold present, the hold starts when the ED hold If there is an ED hold present, the hold starts when the ED hold was initiated was initiated

ED HoldED Hold 24 hour hold24 hour hold Initiated by an ED physicianInitiated by an ED physician Based on same criteria as a 5150Based on same criteria as a 5150 If initiated, starts the “clock”If initiated, starts the “clock”

Psychiatric holds (cont)Psychiatric holds (cont)

52505250 14 day continuation of 515014 day continuation of 5150 Same criteria as 5150Same criteria as 5150 Can be started even if original 5150 was Can be started even if original 5150 was

discontinued, but must be back-dated to when discontinued, but must be back-dated to when 5150 would have expired5150 would have expired

Patients have opportunity to demand physicians Patients have opportunity to demand physicians show probable cause (go to court to dispute the show probable cause (go to court to dispute the hold)hold)

An aside on involuntary medicationsAn aside on involuntary medications

Riese decisionRiese decision Case law based on Riese v. St. Mary’s Hospital Case law based on Riese v. St. Mary’s Hospital

(1989) decision(1989) decision Involves a capacity evaluation specifically to refuse Involves a capacity evaluation specifically to refuse

psychotropic medicationspsychotropic medications Allows clinicians to administer psychotropic Allows clinicians to administer psychotropic

medications against a patient’s willmedications against a patient’s will• Does not apply to non-psychotropic medicationsDoes not apply to non-psychotropic medications

Patients must be on a psychiatric hold concurrentlyPatients must be on a psychiatric hold concurrently Does not extend to emergent administration Does not extend to emergent administration

Competency and Capacity Competency and Capacity

Competence and Capacity are Competence and Capacity are interchangeable terms that have the interchangeable terms that have the same definitionsame definition

a. Truea. Trueb. Falseb. False

The following is true of capacity:The following is true of capacity:

a.a. A declaration that a patient lacks A declaration that a patient lacks capacity capacity is permanentis permanent

b.b. An assessment of capacity covers all An assessment of capacity covers all medical decisionsmedical decisionsc. c. Demented patients by definition lack Demented patients by definition lack capacitycapacityd. d. If a patient lacks capacity in one area If a patient lacks capacity in one area

he/she lacks capacity in all areashe/she lacks capacity in all areas

or

Competence vs. CapacityCompetence vs. Capacity

CompetenceCompetence is a legal term used to describe a is a legal term used to describe a person’s global ability to make decisionsperson’s global ability to make decisions Decided by a court/judgeDecided by a court/judge Permanent unless overturned by a court/judgePermanent unless overturned by a court/judge A guardian or conservator is appointed to make decisions A guardian or conservator is appointed to make decisions

for the personfor the person CapacityCapacity is a clinical assessment of a patient’s ability is a clinical assessment of a patient’s ability

to make specific healthcare decisionsto make specific healthcare decisions Evaluated by physiciansEvaluated by physicians Specific, not globalSpecific, not global Not necessarily a permanent assessmentNot necessarily a permanent assessment

Ganzini et al., 2005Ganzini et al., 2005

CapacityCapacity

No formally accepted clinical standardNo formally accepted clinical standard A variety of instruments exist, but are not widely A variety of instruments exist, but are not widely

used in clinical practiceused in clinical practice Likely a more reliable assessment than MD judgmentLikely a more reliable assessment than MD judgment Validity yet to be established in non-research Validity yet to be established in non-research

populationspopulations MacArthur Competence Assessment Tool for MacArthur Competence Assessment Tool for

Treatment (MacCAT-T) (Grisso & Appelbaum, Treatment (MacCAT-T) (Grisso & Appelbaum, 1995)1995)

CapacityCapacity

Decision making capacity evaluated along 4Decision making capacity evaluated along 4

standards found in the law (Appelbaum and standards found in the law (Appelbaum and Grisso, 1988, 1995)Grisso, 1988, 1995)

1.1. Pt communicates a clear and consistent choicePt communicates a clear and consistent choice

2.2. Pt understands the situationPt understands the situation

3.3. Pt understands the consequences of his/her choice, Pt understands the consequences of his/her choice, including risks/benefits/alternativesincluding risks/benefits/alternatives

4.4. Pt rationally manipulates informationPt rationally manipulates information

Capacity Capacity

Different courts may emphasize different Different courts may emphasize different standardsstandards

Patients may demonstrate varying degrees of Patients may demonstrate varying degrees of ability among the 4 standardsability among the 4 standards Need to determine acceptable threshold Need to determine acceptable threshold

Universally accepted that patients should be Universally accepted that patients should be evaluated across all 4 standardsevaluated across all 4 standards

Patients must meet acceptable threshold on all Patients must meet acceptable threshold on all 4 standards4 standards

Capacity Capacity

Most often evaluated when patient is refusing Most often evaluated when patient is refusing to follow physician recommendationto follow physician recommendation Cannot assume that patient has capacity just Cannot assume that patient has capacity just

because they are in agreement because they are in agreement Standard of “proof” increased (“sliding scale”)Standard of “proof” increased (“sliding scale”)

• When the complexity and seriousness of the issue and When the complexity and seriousness of the issue and risks are significantrisks are significant

• When the patient’s decision is in opposition to what is When the patient’s decision is in opposition to what is recommendedrecommended

Case of Mr. RCase of Mr. R

Case of Mr. RCase of Mr. R

Pt is a 61 yo WM with h/o chronic schizophrenia self presented with Pt is a 61 yo WM with h/o chronic schizophrenia self presented with 4 day h/o abd swelling and distention. During the course of his 4 day h/o abd swelling and distention. During the course of his work-up, a large 10cm infrarenal AAA was discovered. Vascular work-up, a large 10cm infrarenal AAA was discovered. Vascular consultation was requested, and pt was offered surgical intervention, consultation was requested, and pt was offered surgical intervention, which he refused. Psychiatry consultation was requested to evaluate which he refused. Psychiatry consultation was requested to evaluate pt’s capacity to refuse this procedure. On exam, pt was minimally pt’s capacity to refuse this procedure. On exam, pt was minimally interactive and lethargic, but consistently stated that he did not want interactive and lethargic, but consistently stated that he did not want the surgery. He was able to state understanding of his condition and the surgery. He was able to state understanding of his condition and that he might die if he did not have the surgery. However, when that he might die if he did not have the surgery. However, when asked why he was declining the intervention, pt stated “I just don’t asked why he was declining the intervention, pt stated “I just don’t want it.” He was unable to elaborate despite many different want it.” He was unable to elaborate despite many different approaches to clarify his reasoning across multiple visits. Pt approaches to clarify his reasoning across multiple visits. Pt repeatedly asked to go home. Because he was deemed a poor repeatedly asked to go home. Because he was deemed a poor surgical candidate due to his endstage liver disease, the primary surgical candidate due to his endstage liver disease, the primary team (Medicine) felt that the patient should not have the surgery, team (Medicine) felt that the patient should not have the surgery, and his wishes to go home should be honored. and his wishes to go home should be honored.

Capacity Capacity

Need to think through the ultimate goal of Need to think through the ultimate goal of evaluating capacity in each caseevaluating capacity in each case May not achieve desired outcome, i.e., compliance May not achieve desired outcome, i.e., compliance

with outpt medicationswith outpt medications Achieving goal may require steps that are not Achieving goal may require steps that are not

practical or easily accomplished, i.e., forcing practical or easily accomplished, i.e., forcing someone to wear nasal cannulasomeone to wear nasal cannula

Must anticipate that there will be other, related Must anticipate that there will be other, related outcomes, i.e., reduced quality of life, increased outcomes, i.e., reduced quality of life, increased distress and potential trauma to patient and family, distress and potential trauma to patient and family, deterioration of the physician-patient alliancedeterioration of the physician-patient alliance

CapacityCapacity

Specific to a particular question or issue, not Specific to a particular question or issue, not globalglobal Pts can have capacity in one area and not in Pts can have capacity in one area and not in

anotheranother Case of Ms. S Case of Ms. S

Patients with cognitive or mental impairments Patients with cognitive or mental impairments do not necessarily lack capacitydo not necessarily lack capacity But, may be more likely to lack capacityBut, may be more likely to lack capacity

Patients can regain capacity Patients can regain capacity

Case of Ms. SCase of Ms. S

Pt is a 66 yo DWF with h/o chronic schizophrenia, large uterine Pt is a 66 yo DWF with h/o chronic schizophrenia, large uterine fibroids, and chronic vaginal bleeding adm from OSH for treatment fibroids, and chronic vaginal bleeding adm from OSH for treatment of bilateral LE pressure necrosis ulcers. Pt had been found down in of bilateral LE pressure necrosis ulcers. Pt had been found down in her trailer by her landlord after about 3 days. It was thought that pt, her trailer by her landlord after about 3 days. It was thought that pt, weak from blood loss from her fibroids, had fallen and was unable weak from blood loss from her fibroids, had fallen and was unable to get up. Pt consented to work-up and treatment for her LE ulcers to get up. Pt consented to work-up and treatment for her LE ulcers but refused work-up for her uterine bleeding/mass. Psychiatric but refused work-up for her uterine bleeding/mass. Psychiatric consultation was sought to evaluate capacity to refuse this work-up. consultation was sought to evaluate capacity to refuse this work-up. On exam, pt continued to refuse work-up, and said that she does not On exam, pt continued to refuse work-up, and said that she does not have cancer, because “the voice of God” told her. She further stated have cancer, because “the voice of God” told her. She further stated that she does not believe in “allopathic medicine” and will treat the that she does not believe in “allopathic medicine” and will treat the problem with her own homeopathic remedies. However, when problem with her own homeopathic remedies. However, when asked why she is consenting to treatment for her LE ulcers, pt asked why she is consenting to treatment for her LE ulcers, pt replied, “I would lose my legs.” She was unable to reconcile this replied, “I would lose my legs.” She was unable to reconcile this contradictory statement with her refusal to consent to w/u for her contradictory statement with her refusal to consent to w/u for her uterine mass.uterine mass.

CapacityCapacity

Decision should in general be consistent with Decision should in general be consistent with patient’s prior known values/beliefspatient’s prior known values/beliefs

Efforts should be made to help patients Efforts should be made to help patients perform their bestperform their best Multiple explanationsMultiple explanations Having familiar, trusted people present (family, Having familiar, trusted people present (family,

caregivers)caregivers) Examiner of similar ethnic/cultural backgroundExaminer of similar ethnic/cultural background Translator if appropriateTranslator if appropriate

CapacityCapacity

Professional dutyProfessional duty

Patient autonomyPatient autonomy Legal systemLegal system

CapacityCapacity

The actual decision itself is not as important as the The actual decision itself is not as important as the processprocess by which the decision was made by which the decision was made

Difference between lack of capacity and poor Difference between lack of capacity and poor judgmentjudgment Whether the decision would be considered by most people Whether the decision would be considered by most people

to be the wisest or most correct choice is not required for to be the wisest or most correct choice is not required for capacity (Grisso and Appelbaum, 1998)capacity (Grisso and Appelbaum, 1998)

Conflict between preserving personal autonomy and Conflict between preserving personal autonomy and upholding “public interest” in preserving life (Hurst, 2004)upholding “public interest” in preserving life (Hurst, 2004)

• Seat belt, motorcycle helmet, cell phone use lawsSeat belt, motorcycle helmet, cell phone use laws Case of Mr. F Case of Mr. F

Case of Mr. FCase of Mr. FPt is a 71 yo DAAM with DM2, CAD, CHF, HTN, chart h/o Pt is a 71 yo DAAM with DM2, CAD, CHF, HTN, chart h/o schizoaffectiveschizoaffective disorder/schizophrenia, long history of medication disorder/schizophrenia, long history of medication and f/u noncompliance, BIBA to ED with c/o CP. Pt has a h/o and f/u noncompliance, BIBA to ED with c/o CP. Pt has a h/o multiple presentations to the ED with similar sx and often refuses multiple presentations to the ED with similar sx and often refuses w/u and demands to leave AMA. As in the past, pt refused all w/u and demands to leave AMA. As in the past, pt refused all attempts at work-up or physical exam and demanded food. attempts at work-up or physical exam and demanded food. Psychiatric consultation was requested to evaluate capacity to refuse Psychiatric consultation was requested to evaluate capacity to refuse work-up of acute CP. EMS Captain T, who is familiar with pt, work-up of acute CP. EMS Captain T, who is familiar with pt, stated that pt has been inadequately clothed (wearing hospital stated that pt has been inadequately clothed (wearing hospital pajamas), eating out of garbage cans, and soiling himself on a pajamas), eating out of garbage cans, and soiling himself on a regular basis. He recommended conservatorship. On exam, pt regular basis. He recommended conservatorship. On exam, pt refused to discuss the elements of his current presentation or refused to discuss the elements of his current presentation or proposed treatment. He denied hallucinations, there was no proposed treatment. He denied hallucinations, there was no evidence of thought disorder, and no delusional content was evidence of thought disorder, and no delusional content was elicited. Per collateral, pt is not in psychiatric treatment but was elicited. Per collateral, pt is not in psychiatric treatment but was conserved for 2 months one year ago. Pt however, eloped from the conserved for 2 months one year ago. Pt however, eloped from the L-facility and conservatorship was not re-instated/further pursued. L-facility and conservatorship was not re-instated/further pursued.

Who can determine capacity?Who can determine capacity?

a.a. A psychiatristA psychiatristb.b. A neurologistA neurologistc.c. A judgeA judged.d. A juryA jurye.e. Any MDAny MD

Capacity Capacity

Can be evaluated by any MDCan be evaluated by any MD Psychiatrist evaluation is not requiredPsychiatrist evaluation is not required Most often best assessed by primary clinicians Most often best assessed by primary clinicians

caring for patientcaring for patient• Know the patient and his/her values system betterKnow the patient and his/her values system better

• Are able to multiple evaluations over timeAre able to multiple evaluations over time

• Are more familiar with procedure or issue proposedAre more familiar with procedure or issue proposed

When to evaluate capacityWhen to evaluate capacity

Often this evaluation occurs unconsciouslyOften this evaluation occurs unconsciously Not practical to evaluate capacity formally for Not practical to evaluate capacity formally for

every decision a patient makesevery decision a patient makes Certain situations call for more explicit Certain situations call for more explicit

evaluationevaluation Abrupt changes in mental statusAbrupt changes in mental status When patients refuse treatmentWhen patients refuse treatment When the proposed treatment has a higher When the proposed treatment has a higher

risk/benefit ratiorisk/benefit ratio

When to evaluate capacityWhen to evaluate capacity

Certain situations call for more explicit evaluationCertain situations call for more explicit evaluation When patients have one or more risk factors for impaired When patients have one or more risk factors for impaired

decision makingdecision making• h/o cognitive impairmenth/o cognitive impairment

• h/o mental illnessh/o mental illness

• Current active psychiatric sx – depression, anxiety, psychosisCurrent active psychiatric sx – depression, anxiety, psychosis

• Patient is of a different culturePatient is of a different culture

• Patient does not speak English or has limited English skillsPatient does not speak English or has limited English skills

• Patients who are involuntarily hospitalizedPatients who are involuntarily hospitalized

• Age – older or younger (younger adult)Age – older or younger (younger adult)

Capacity in Special PopulationsCapacity in Special Populations

Case of Ms. JCase of Ms. J

Pt is a 55 yo AAF with h/o AF, DM2, stroke on Pt is a 55 yo AAF with h/o AF, DM2, stroke on coumadin, and chart h/o psychotic disorder coumadin, and chart h/o psychotic disorder who self presented with back pain, and found who self presented with back pain, and found to have subtherapeutic INR. Pt was adm for to have subtherapeutic INR. Pt was adm for adjustment of anticoagulation therapy. Pt has a adjustment of anticoagulation therapy. Pt has a h/o noncompliance with attending Coumadin h/o noncompliance with attending Coumadin clinic and with this medication. Psychiatric clinic and with this medication. Psychiatric consultation was requested to conserve patient. consultation was requested to conserve patient. Pt refused to be interviewed or discuss her care Pt refused to be interviewed or discuss her care in any way.in any way.

Capacity: When the patient refuses Capacity: When the patient refuses capacity evaluationcapacity evaluation

Cannot assume that the patient does not have Cannot assume that the patient does not have capacitycapacity

Efforts should be made to identify a person Efforts should be made to identify a person with whom the patient feels comfortable with whom the patient feels comfortable discussing the issuediscussing the issue

Capacity: When the patient refuses Capacity: When the patient refuses capacity evaluationcapacity evaluation

Weigh the risk to the patient if his/her decision Weigh the risk to the patient if his/her decision is carried outis carried out If high, then would proceed as if the patient lacked capacityIf high, then would proceed as if the patient lacked capacity

• Explain this process to the patientExplain this process to the patient Balance this with considerations of Balance this with considerations of

• The potential harms to the patient, both short and long-termThe potential harms to the patient, both short and long-term

• The short and long term practicality of carrying out interventions The short and long term practicality of carrying out interventions against a patient’s willagainst a patient’s will

Hurst, 2004Hurst, 2004

Case of Mr. MCase of Mr. M

59 yo WM with HCV cirrhosis, DM2, HTN, and chart h/o 59 yo WM with HCV cirrhosis, DM2, HTN, and chart h/o chronic paranoid schizophrenia self-presented with c/o abd, chronic paranoid schizophrenia self-presented with c/o abd, back, and eye pain with reduced visual acuity. Pt adm to back, and eye pain with reduced visual acuity. Pt adm to Medicine for treatment of presumed SBP, ARF/CRF, and Medicine for treatment of presumed SBP, ARF/CRF, and endophthalmitis. Pt however, refused paracentesis and intra-endophthalmitis. Pt however, refused paracentesis and intra-ophthalmic injection of abx. Treatment, though deemed to be ophthalmic injection of abx. Treatment, though deemed to be urgent, was delayed in order to obtain psychiatric consultation urgent, was delayed in order to obtain psychiatric consultation to evaluate pt’s capacity to refuse these interventions. Pt able to evaluate pt’s capacity to refuse these interventions. Pt able to discuss basics of his current medical conditions but unable to discuss basics of his current medical conditions but unable to appreciate the consequences of his choice, nor able to to appreciate the consequences of his choice, nor able to discuss alternatives. He was unable to rationally explain his discuss alternatives. He was unable to rationally explain his decision nor was he consistent in that he stated desire to get decision nor was he consistent in that he stated desire to get help for his conditions but refused to cooperate with proposed help for his conditions but refused to cooperate with proposed medical interventions. medical interventions.

Capacity and the psychiatric patientCapacity and the psychiatric patient

Capacity is assessed in the same way with the same Capacity is assessed in the same way with the same standardsstandards

Capacity determination is absolute (yes/no) Capacity determination is absolute (yes/no) regardless of cause of incapacity regardless of cause of incapacity

Capacity may be restored with treatment of active Capacity may be restored with treatment of active psychiatric sx, if they are determined to be the cause psychiatric sx, if they are determined to be the cause of incapacity, and of incapacity, and if intervention can be safely if intervention can be safely delayeddelayed May request psychiatric consultation for guidanceMay request psychiatric consultation for guidance Ultimately the responsibility of primary physician caring Ultimately the responsibility of primary physician caring

for patientfor patient

Capacity: Capacity: The emergent/urgent situationThe emergent/urgent situation

When capacity cannot be evaluated When capacity cannot be evaluated (i.e.,unconscious patient) and there are no (i.e.,unconscious patient) and there are no readily available surrogatesreadily available surrogates Shoot first, ask questions later?Shoot first, ask questions later?

• Intervention is not delayed to evaluate capacity to Intervention is not delayed to evaluate capacity to consentconsent

Widely accepted standard: The two physician Widely accepted standard: The two physician consent, “emergency privilege” (Derse, 2005)consent, “emergency privilege” (Derse, 2005)

• 2 physicians need to independently agree and document 2 physicians need to independently agree and document that there is an imminent threat to life or limb and may that there is an imminent threat to life or limb and may proceed proceed

Capacity: Capacity: The emergent/urgent situationThe emergent/urgent situation

When capacity cannot be evaluated When capacity cannot be evaluated (i.e.,unconscious patient) and there are no (i.e.,unconscious patient) and there are no readily available surrogatesreadily available surrogates Best interests standardBest interests standard

• Based on best interests as a whole for patientsBased on best interests as a whole for patients Maximizes overall/long-term benefits, minimizes burdensMaximizes overall/long-term benefits, minimizes burdens Compares burdens, consequences, potential complications of Compares burdens, consequences, potential complications of

treatment vs. non-treatmenttreatment vs. non-treatment

• What a “reasonable person” would consider acceptable What a “reasonable person” would consider acceptable under similar circumstancesunder similar circumstances

• Can be decided by the physicianCan be decided by the physician

Grisso and Appelbaum, 1998, Kopelman, 2007Grisso and Appelbaum, 1998, Kopelman, 2007

ConservatorshipConservatorship

Ms. P is an 85 yo WWF with h/o DAT, HTN, COPD and CAD. Ms. P is an 85 yo WWF with h/o DAT, HTN, COPD and CAD. She was admitted with dehydration, ARF, and FTT. Pt lives She was admitted with dehydration, ARF, and FTT. Pt lives alone, and it was determined that pt has not been eating or alone, and it was determined that pt has not been eating or leaving her home because she believes her son has been leaving her home because she believes her son has been poisoning her food and is trying to kill her. She has also stopped poisoning her food and is trying to kill her. She has also stopped paying her bills, taking all of her money out of her bank account paying her bills, taking all of her money out of her bank account and hiding it under her mattress because she fears her son is also and hiding it under her mattress because she fears her son is also after her money. SW states “You have to conserve Ms. P.” after her money. SW states “You have to conserve Ms. P.” Which type of conservatorship is most appropriate for Ms. P?Which type of conservatorship is most appropriate for Ms. P?

a.a. Probate conservatorshipProbate conservatorshipb.b. LPS conservatorshipLPS conservatorship

Probate conservatorship and LPS Probate conservatorship and LPS conservatorship confer the same powers to conservatorship confer the same powers to the conservatorthe conservator

a.a. TrueTrueb.b. FalseFalse

ConservatorshipConservatorship Two “tracks”Two “tracks”

Probate conservatorshipProbate conservatorship LPS (Lanterman-Petris-Short Act)LPS (Lanterman-Petris-Short Act)

Choice of track depends on nature and etiology of Choice of track depends on nature and etiology of incapacityincapacity

Powers of conservatorPowers of conservator Must be petitioned for and specifically grantedMust be petitioned for and specifically granted PersonPerson

• MedicalMedical• PsychiatricPsychiatric• MedicationsMedications

Estate (financial)Estate (financial)

Probate ConservatorshipProbate Conservatorship

Patient deemed to be incompetent to make Patient deemed to be incompetent to make decisions in regard to person and/or estatedecisions in regard to person and/or estate ““clear and convincing evidence”clear and convincing evidence”

Usually in cases of dementia or other organic Usually in cases of dementia or other organic brain disordersbrain disorders Can last indefinitelyCan last indefinitely Court reviewed every 2 yearsCourt reviewed every 2 years

Often a family member or close associate of Often a family member or close associate of patient assumes role of conservatorpatient assumes role of conservator

Probate ConservatorshipProbate Conservatorship

Specific powers of conservator must be Specific powers of conservator must be established by the courtestablished by the court Does not include mental health treatmentDoes not include mental health treatment

Placement can be an issuePlacement can be an issue

LPS ConservatorshipLPS Conservatorship

Based on Lanterman-Petris-Short Act enacted July 1, Based on Lanterman-Petris-Short Act enacted July 1, 19691969

Patient is demonstrated as gravely disabled Patient is demonstrated as gravely disabled as a as a result of a mental disorder or chronic alcoholismresult of a mental disorder or chronic alcoholism ““beyond a reasonable doubt”beyond a reasonable doubt”

Conservatorship is for a one year term and can be Conservatorship is for a one year term and can be renewedrenewed Not permanentNot permanent

Patients have opportunities to dispute conservatorship Patients have opportunities to dispute conservatorship

LPS ConservatorshipLPS Conservatorship

Conservators are most often court-appointedConservators are most often court-appointed Specific powers must be establishedSpecific powers must be established

Patients are often initially placed in locked Patients are often initially placed in locked facilities (L-facility)facilities (L-facility)

Conservator can decide to place patients in Conservator can decide to place patients in alternative, less restrictive settingsalternative, less restrictive settings

SummarySummary

Decision making in the hospital setting is Decision making in the hospital setting is common and can encompass issues relating to common and can encompass issues relating to patient autonomy, safety, and preservation of patient autonomy, safety, and preservation of life, both in quantity and qualitylife, both in quantity and quality

Knowledge of holds, capacity, and Knowledge of holds, capacity, and conservatorship can help the clinician in conservatorship can help the clinician in his/her efforts to care for patientshis/her efforts to care for patients

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