DATE OF CONSULTATION: MM/DD/YYYY
REQUESTING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Psychiatry consultation to assess for decisional capacity.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic male with no known past psychiatric history admitted for multiple medical problems. Psychiatry was called to assess for decisional capacity. The patient did not have the capacity to make healthcare decisions and the patient’s brother had signed as the surrogate decision-maker. Upon interview, the patient was found to be not oriented to place, was not able to give his full name unless it was stated, and he was able to recognize his name. The patient also was only able to name the year, otherwise was not oriented to situation.
The patient denied that he knew his reason for hospitalization, denied knowing that he had a complicated course of hospitalization that required ICU admissions, and could not provide any other information in regards to his medical care. Therefore, the patient is not able to communicate his needs. There is no consistent communication of his decision. He is not able to provide any of the risks and benefits of treatment versus no treatment, and he is unable to process the information provided to him.
PAST PSYCHIATRIC HISTORY: Unknown.
FAMILY HISTORY: As regards psychiatric illness is also unknown.
SOCIAL HISTORY: Per medical chart, the patient is estranged from his family and has a brother, who signed as a surrogate decision-maker, according to the medical record. Other social history is unknown at this time.
PAST MEDICAL AND SURGICAL HISTORY: Includes COPD, seizure disorder, opioid dependence due to chronic back pain, lumbar spinal degenerative changes status post multiple surgeries, history of upper GI bleed, history of ileus, hyperlipidemia, cardiomyopathy, diabetes, acute renal failure requiring hemodialysis, right arm cellulitis, Klebsiella pneumoniae, history of respiratory failure, as well as myocardial infarction.
MENTAL STATUS EXAMINATION: The patient is a (XX)-year-old Hispanic male with notable labored breathing, drowsy, but responsive to verbal stimuli, with intermittent eye contact. No psychomotor agitation or retardation noted. Speech is very labored secondary to his mild respiratory distress, whispering when speaking and very difficult to understand. Mood is okay. Affect is euthymic. Thought content is unable to be assessed secondary to the patient’s mild respiratory distress. Otherwise, he did not verbalize any thoughts of self-injury or harm to others and was not noted to be responding to internal stimuli during interview. Thought process demonstrated poverty of thought. Insight and judgment was determined to be poor to limited.
Axis I: Delirium.
Axis II: Deferred.
Axis III: Multiple medical conditions, as noted above.
Axis IV: Problems with social support, multiple medical conditions.
Axis V: Global Assessment of Functioning of 0 to 5.
IMPRESSION: This (XX)-year-old male with no known past psychiatric history was admitted for multiple medical problems. The patient at this time does not have the decisional capacity for healthcare decisions. According to the medical chart, the patient was found to have decisional incapacity with a surrogate decision-maker as his brother. Again, the patient was unable to communicate his needs to make a consistent choice and unable to provide the risks and benefits of treatment nor to process the information.
RECOMMENDATIONS: Social work aid to determine proper surrogate decision-maker. If the patient’s brother is uncomfortable with being the surrogate decision-maker, may want to consider getting public guardianship. Otherwise, recommend that medical team work with the patient’s brother in regards to healthcare decisions. Case and plan discussed with and agreed by attending physician.