Psychiatry Station 3

 

Station 3

What’s that donkey doing there?

 

Candidate Instructions

Setting:

You are a Foundation Year 2 doctor working a night shift in the acute medical unit. It is currently 02:00am. You have been asked to see the following patient because they are wanting to leave the ward.


Name: Mary Jones

This patient presented yesterday with fever and cough. They have been diagnosed with a CURB 3 pneumonia and started on IV antibiotics.


Tasks:

1.Take a history from the patient with a view to assssing their capacity to make the decision to leave the hospital.

2.Once you have completed your assessment, please explain your impression of their capacity to the exmainer.

3.Explain to the examiner what your next steps in the management of this situation would be.

You are not required to examine the patient.

Simulated Patient Instructions

Briefing

Diagnosis: A patient without capacity to make the decision to leave the hospital.

You are Mary Jones, an 81-year-old woman.

You are currently feeling very upset and anxious because you don’t know where you are or why you are here. You want to go home to your dog.

Appearance and Behaviour

You have a CURB 3 pneumonia and have developed acute delirium (but you can’t remember this!).  You are confused, upset and are packing your bags to go home. You are, however, amenable to sitting down and talking to the doctor.  You do NOT have the capacity to make the decision to self-discharge from the hospital - son’t tell them this.

Opening statement

“Please doctor, they won’t let me go home! I have a dog and he’ll be wondering where I am - he’ll be hungry! Please help me to the bus so I can get home.”

Information to Give Freely

You do not know where you are or why you’re here.

Presenting Complaint

Physical symptoms:

  • You are feeling upset at the moment.
  • You have had a little bit of a cough but feel otherwise OK. You have been bringing up phlegm but don’t know what colour.
  • You say ‘no’ or ‘I don’t know’ to any other physical symptoms that are asked. 

    • Confusion screen:

  • You are spontaneously alert but clearly confused.
  • You can tell them your name and DOB (1st Feb 1943) but cannot remember your age. 
  • You think you are in ‘the hotel’ (you don’t know which one).
  • You think it is 4pm in the afternoon.
  • You think the year is 2007, and you get the day/date/month incorrect if asked. 
  • If asked, you cannot state the months of the year backwards (you start at Decemeber and then go to February etc). 

    • Specific capacity questions:

  • If you are told that you’re in the hospital, you should appear surprised and wonder why on earth you are there.
  • You do not believe that you are currently unwell or needing any medical treatment. You repeat that you need to get home to feed your dog. 
  • You do not think that there would be a risk to your health if you were to go home now 
  • If you are asked how you would get home, you say that you would take the bus. 
  • If you are asked to repeat where you are or why you are here, you cannot remember and say that you must be in ‘the shopping center’

    • Other psychiatric symptoms:

  • You deny any thoughts/plans of self-harm or suicide
  • Your mood is usually happy when you are not here!
  • You deny any recent changes in your appetite/weight/sleep/energy
  • If you are asked specifically ‘have you had any hallucinations’, you should reply ‘no!’. HOWEVER if you are asked if you have seen or heard anything unusual in this building, you should say that you were surprised to see a donkey outside your window earlier but presume that they must be grazing in the field nearby. 
  • If asked, you do not believe that anybody is ‘out to get you’.

    • Past Medical History

    You can’t remember any of your past medical or psychiatric history - you just say ‘no I’m fine’ when asked. You have never felt like this before.

    Drug History

    Prescribed - You think your doctor recently prescribed you a cholesterol tablet

    Over the counter - you sometimes take paracetamol when you need it 

    Allergies - none

    Family History

    Your family have always been very healthy 

    Social History

    Smoking history - Never smoked.

    Alcohol - No alcohol intake.

    Illicit drugs- No.

    Job - You’re a retired teacher

    Home:

  • You live at home alone 
  • Your daughter lives nearby and helps you sometimes
  • You don’t have any carers and do your own ADLs independently

    • Systems Review

    You deny any physical symptoms asked, other than having a mild cough. 

    Ideas / Concerns / Expectation

    You just want to be able to go home and see your dog 

    Discussion / Questions

    Use the following as a summary of prompts on how to respond to the candidate’s attempts to assess your capacity to leave at any point in the interaction:

    Understanding - You do not why you are here, or where you are. 

    Retention - Even if the candidate provides a good explanation of why you are here, you are unable to retain this information.

    Weigh up - You do not understand that it would be unsafe for you to go home, even if they explain this clearly multiple times. You have no insight into the fact your illness could be life threatening if you leave.

    Start the Timer and Begin

    Intro

     

    Presenting complaint

     

    Assesses the patient’s cognition in a structured manner (e.g. 4AT). Asks about:


    Assesses the patient’s understanding of their current situation and risks associated with making the decision to self-discharge including:

    Past Medical History

     

    Drug History

     

    Family History

     

    Social History

     

    Systems Reviews

     

    Ideas, Concerns, Expectations

     

    Diagnosis

     

    This is because they are not able to:

  • Understand why there are in hospital or the treatment that is required for their pneumonia.
  • Understand the risks associated with making the decision to self-discharge (they do not believe they are unwell or are at risk of becoming very unwell without treatment).
  • Retain the information relevant to making this decision.

    • Management

     

    Management proposed should progress from least to most restrictive:

    Submit for Scoring

    Tags | Psych | Psychiatry | Capacity Assessment | Mental Health

    Station Written by: Dr Olivia Impey

    Peer Reviewed by: Dr Benjamin Armstrong

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