Actually the issue of determining competency is technically a legal call, not a psychiatric one. A psychiatrist can render an opinion about decision making capacity (which must be clearly defined as to the type of decision the patient is being asked to make), but ultimately a judge makes the call.

As a psychiatrist, whenever I get consulted to see a patient for "competency", the first thing I have to do is find out "competent for what?". Many times, I have to tell the requesting physician that people are allowed to make bad decisions about their health - that not wanting to follow a doctor's recommendations is not automatically grounds to call someone incompetent.

In those instances where the patient is not competent (that is, they do not understand the nature of their disease, the treatment being recommended, the risks of refusing treatment and the risks of having the treatment), I still cannot say that he or she is incompetent. I can only say that based on my examination, the person appears to not understand what it is they are refusing, and that a legal determination of competency should be the next step. In short, the system has a number of safeguards to try to prevent people from being railroaded into treatments, both medical and psychiatric.

You are absolutely right. The issue of competency is a legal one and consulting a psychiatrist is only dragging another opinion into the fray to cover the butts of those who are performing the unconsented (or consented) procedure.

The issue in this case is different but it competence does come into play. The patient comes in to the trauma room with a head injury. A rectal examination is the standard of care during a trauma evaluation, so by not performing a rectal examination they would be deviating from the standard of care (and thereby opening themselves up to liability.) The patient refuses the rectal examination, however the examining physician has to decide immediately (because that is the way traumas work) whether or not the patient is competent or has the head injury rendered him incompetent to refuse care. If the patient is competent and refuses care and ends up having a spinal cord injury and is paralyzed for the rest of his life then that's his business and the physician will document his refusal and he's off the hook. If the patient is incompetent because of the head inury and refuses care and the examination is deferred and then ends up having a spinal cord injury and is paralyzed for the rest of his life then the physician is negligent and therefore liable.

It sounds to me, judging from the articles about this case, that the patient was combative and punched a staff member. Typically, when that is the case, the presumption has to be the the patient's irrational behavior (and any violent act in the hospital after you have been injured is irrational behavior) is secondary to the head injury and that an orderly workup of that head injury is absolutely necessary and the patient is therefore deemed incompetent. It sounds like this particular patient was pretty crazy because he was sedated and intubated so that the hospital staff could completely the necessary workup.

Unfortunately, the timeline of these workups is such that consulting a psychiatrist is not feasible and you rely on the judgment of the attending physician. And sometimes an unconsented procedure is performed. However, the potential outcomes from performing vs. not performing the procedure are weighed and somebody has to decide how badly they need to know the results. And I'll tell you--that doctor in the ER made a decision that 100% of physicians who have ever worked a trauma would agree with. I would rather get sued by an neurologically intact patient who is claiming PTSD (of course he better get over his fear by the time he gets to a prostate or colon trouble age and really gets a taste of rectal examinations) than by a quadriplegic patient steering his wheelchair with his tongue and speaking in time with his ventilator. Especially all over a no risk five second rectal examination.

I'm surprised that a lawyer took this case as I can't imagine the the potential payout is high enough to make it worth their while. If I were on the jury I would tell him to man up and deal with it.

I'm not sure I agree with your assessment of "irrational behavior". Striking someone who is attempting to force something into your anus against your will seems to me to be a perfectly reasonable and sane thing to do. The doctor should have respected the patient's wishes.

Well, that, unfortunately, is a judgment call that the physician has to make based on the decision processes that I described in the rest of the post. That doctor didn't know if the patient's frontal lobe was slowly filling with blood and that was the reason why the patient was combative, he did not know if the patient was drunk or high on PCP and that was the reason why he was combative. He had to assume the worst possible injury was present and evaluate based on that. It may be an unconsented examination, but given the circumstances it was a reaonable one.

And let me tell you. Punching a doctor under any circumstances is irrational behavior. And that plaintiff had a heck of a nice doctor who continued his examination despite the violence. When I treat patients in the ER and one of them gets violent (or threatens violence) and I determine that the patient is altered by alcohol, drugs, or just poor disposition I walk away and do not come back, regardless of the severity of injury. So you better be polite in the ER.

I think the order of the events is important here. The patient was combative AFTER what seems to be repeated refusals and AFTER he was forcibly restrained. In that situation I don't think he thought he had any other options and acted out of desperation. You don't check your civil liberties in at the door when you go to an emergency room and it sounds as if that's the case if the bar for assuming incompetence is that low. The doctor should have walked away and the patient should have suffered the consequences for refusing treatment.

I'm not sure of the timeline here and rereading a fair number of the articles regarding this doesn't specify when exactly he became combative. In any case, even if he became combative late in the examination it could be a manifestation of a worsening closed head injury and the examination would still be the same. And while I agree that you do not check your civil liberties at the door of the hospital you do have to recognize that you are in an unusual (and probably unique) situation and that no one there is acting in a malicious fashion. So to some degree you just have to sit back and take it. I still believe that striking a physician was uncalled for (although I do agree that arresting him and charging him was probably unnecessary.) I still don't understand what the big deal is about a rectal exam, considering every man in the country has to have it now and again and, while unpleasant, is certainly not torture.

Some other discussion on this topic:

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I have to agree that hitting the examining physician is never a good idea! I was hit once in the ER when I was a resident. I was asked to see a patient about possible involuntary commitment due to dangerousness. His girlfriend had filed a petition and I needed to evaluate him. He was obviously intoxicated, and I was ready to let him sleep in the ER and re-evaluate him in the morning when he would be sober. Then he tried to choke me! So we committed him. Of course, I did not have him arrested or charged - he was clearly not someone who was in control of his actions and his decision making skills were obviously impaired...

As I posted:

Treating the wound and not the person. If you were my doctor, I would ask that you walk away and never return! You sound like one of those doctors that have a god complex. You would force somone to have an invasive procedure, but if he became combative you wouldn't care at all what happens to him.

I hate that term "God complex." Everytime someone wants to criticize a physician they trundle it out as if it imparts some kind of moral superiority.

I live in a world in which you accept personal responsibility for your behavior. That means you behave appropriately and with courtesy. And if you decide to go out and do drugs or get drunk or just be a huge jerk and then show up in the emergency room and decide to take a swing at the guy who's trying to help you, then I take it as a de facto refusal of medical care. There is nothing in the hippocratic oath about taking a punch from a patient. I just walk away from those situations. If the has an ugly scar down his or her face because he or she wouldn't sit quietly for a nice laceration repair then that is the fruit of their poor behavior. Be polite in the emergency room or don't bother showing up.

Polite is one thing and sticking up for yourself when you are being forced to do something is another. I'm sure this guy was polite until he was butt raped. If he refuses prescribed treatment he can be told of the consequences and made to sign a waiver. He could have been monited for awhile and released with an occult blood kit to keep checking for blood in the stool. This is what the doctor was really after is the money for this occult blood test anyway. He didn't need to do a rectal in order to get the money. He already had his money for the trauma eval. The patient could have collected his occult blood X3 and the doctor would have gotten his money anyway. Most patients will bring them back. What this doctor was afraid of was not getting his money for the OCCX3. He was willing to rape in order to get it. He has been coached to do this in order to get more revenue for the hospital.

I don't think that this is really the same thing. Your patient was obviously messed up to where the head injury guy was much more coherent and only combative when his civil rights were violated. Up until that point, I'm sure he was civil. Just being able to distinguish between the two should have been proof enough that this guy was competent to make his own decisions. No, I have firsthand knowledge that the medical profession has overstepped its bounds. The absolute last thing that this patient needed was to be knocked unconcious. Any trauma doctor worth anything would know that with a head injury, you want to keep the patient conscious.They could have killed this man just by knocking him out. I don't know what kind of "rectal tone" (another BS medical term) this guy had after they knocked him out but it just goes to show that the patients welfare was not being looked after here. The doctor had a temper tantrum because the guy would not let him ass rape him. Period. End of story. My friend came off a horse lately and hit her head. No one stuck a finger in her butt. My daughter was knocked out in a car accident in Mexico. No one stuck a finger in her butt. No one did it when she was transported to the US either. She was consious and talking and had 27 stitches in her head. What the doctor in New York did was wrong and unnecessary. Talk to women who have had babies and ask them how many unwanted medical procedures have been done on them. Remember that in Victorian times, doctors used to massage a woman's cervix for "hysteria",( in essence, masturbating her). Do you really think that human nature has really changed since then? There will always be those doctors who became doctors in order to have power over other people. Not all doctors have their patient's wellbeing in mind. More and more we are seeing doctors who have THEIR wellbeing in mind.

What a simply moronic synopsis of anecdotal events. Your criteria for appropriate trauma treatment and what a trauma surgeon should or should not do are colored by the "doctor bashing" glasses that you wear. Please keep your moronic drivel to yourself and discuss things that you actually know something about. Do you work for Pete Stark? If not, you should apply for a job immediately. Why don't you come out and tell us what your real agenda is, Marinmom. National Trial Lawyers Association janitor? Ted Kennedy's janitor?

The same kind of people who try to silence others who fight for their civil rights are the same kind of people who enjoy forcing their fingers up peoples butts. You are a sick mother f****r, supersnook. What a fruity name,Supersnook! Why don't you go find someone who likes having a finger shoved up their butts? Or is the forcing the fun part for you? I suspect that this is why you got into the medical profession to begin with. No, buttjammer, I will not be silenced. I have seen doctors abuse patients too much in my years.You are too stupid to even know why you do the things you do. Oh, and I would love to be Pete Stark's janitor. Or Ted Kennedy's for that matter. It would be alot more honest work than forcing rectal exams on people and violating their civil rights. Go shove your Supersnook up your own butt, rapist!

Supersnook, if you had lived in Victorian times, you would have been one of those doctors I wrote about who would massage a woman's cervix for "hysteria", in essence masturbating her. You would have been all over that. You would have written the procedure for it and numerous articles for JAMA on just how to do it and how to bill the woman for it. You sleaze!

Forcing yourself on someone who does not want it is called rape. Plain and simple. This man was willing to risk dying in order to not have a rectal exam. That is his choice and not some f'ing doctor with a God complex. I'll say that again. God Complex! God Complex! God Complex!!! They could have killed this man just by knocking him out! Learn that you can not do something to someone who is coherent enough to say no. The entire issue revolves around the fact that this man was coherent and said no. No means no.Doctors rape in many ways, not just physically. Stop raping people for money, doctors!