Some thoughts on the county’s Adult Protective Services
I have a beef with Nevada County Adult Protective Services. They misled a family as to my role in declaring a patient’s competence. They placed me in a position where it would have been morally unacceptable not to act. These actions cost me more than eight hours and the hospital three days of non-reimbursable time. While APS has responded that they were acting on behalf of the patient, they were unavailable to assist me. In short they dumped this patient on me, while the caseworker supposedly acting on the patient’s behalf went on a two-week vacation.
APS referred a patient to my office for a mental health evaluation. As an internist I am not suited to providing this service any more than removing a gallbladder. Except in the most extreme cases this is not the strength of my training. I am trained in taking care of medical problems including high blood pressure, cholesterol, heart disease, and diabetes. This was explained to both representatives of APS and the patient’s family. Still both persisted until the patient was scheduled.
The patient was brought by her daughter to my office under false pretenses and immediately became angry and defiant when she discovered the true nature of the visit. Still the patient completed a brief mental status evaluation test satisfactorily, then got up and left. Being blind she had difficulty navigating the streets, but adeptly overcame this deficit enlisting the assistance of strangers.
Observing her behavior and knowing her only shelter was with her daughter whom she had left, I decided the patient was a risk to herself. I called 911 and utilized Grass Valley emergency services to get this patient to the emergency room. There the patient proved to have no acute medical problems or reversible causes for dementia or delirium, and county crisis workers determined she did not meet criteria for involuntary hospitalization. The patient agreed to hospitalization and was admitted on the strength of my observations. For the next 48 hours this patient proved to be a model patient with excellent control of her medical problems, and psychologically pleasant patient for the nursing staff. Much to the dismay of her family, she was discharged to the same situation from whence she came. Nothing had changed despite the expenditure of extensive resources.
It appears APS misled the family regarding the physician’s role in the mental competence hearings. In California, medical and psychological evaluations are presented to a judge as evidence; only the judge can make a legal verdict. The role of the internist is to rule out medical criteria for reversible causes of dementia and delirium, not evaluate a patient’s psychiatric condition. The best-case scenario is to obtain these tests through a primary care provider without utilizing the hospital or emergency services; if this is not possible emergency room referrals are appropriate.
One would expect that APS would understand these procedures, sadly APS’ written response to my complaints supports incorrect procedure. Through erroneous referral APS wasted large amounts of scarce community resources (police, ambulance, emergency, hospital, and physician). A more appropriate use of funds is to request that the primary complete the medical portion of the evaluation, or to refer the patient directly to the emergency room. Instead APS follows imprudent, wasteful procedure that misleads families as to the physician’s role in the process. The medical community continues to lobby California legislature to shift the power away from the judge to the doctor in the issue of patient competence. As yet everyone must still tell it to the judge.
Andris E. Radvany, M.D., practices in Nevada City.
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