# Clinical Cases: Consultation-Liaison Psychiatry ## Case 1: Delirium in a Post-Surgical Patient ### Consultation Request "Please evaluate for confusion and agitation. 68 y/o male POD 2 from CABG, now pulling at lines and trying to get out of bed." ### Patient Demographics - **Age:** 68 years old - **Sex:** Male - **Occupation:** Retired teacher - **Current Location:** Cardiac ICU ### History of Present Illness (from chart review and nursing) The patient is a 68-year-old man who underwent three-vessel coronary artery bypass grafting 2 days ago after presenting with unstable angina. The surgery was technically successful without complications. He was extubated on POD 1 and was initially oriented and following commands appropriately. This morning, nursing noted he became acutely confused, did not recognize his wife, and believed he was in a "prison." He attempted to pull out his central line and Foley catheter, requiring soft restraints. He has been intermittently somnolent and agitated throughout the day. His wife states "this is not him at all - he was sharp as a tack before surgery." ### Chart Review **Medical History:** - Coronary artery disease - Type 2 diabetes - Hypertension - Mild chronic kidney disease (baseline Cr 1.4) - Hearing loss (uses hearing aids - not currently in) **Current Medications:** - Morphine PCA for pain - Metoprolol - Aspirin - Atorvastatin - Insulin sliding scale - Famotidine - Diphenhydramine 50 mg PRN for sleep (received x2 last night) **Recent Labs:** - Na: 129 mEq/L (low) - K: 3.2 mEq/L (low) - BUN: 38, Cr: 2.0 (elevated from baseline) - Glucose: 186 mg/dL - WBC: 11.2 - Hgb: 9.8 **Recent Studies:** - Chest X-ray: Post-surgical changes, no infiltrate - ECG: Normal sinus rhythm, post-surgical changes ### Psychiatric Consultation Examination **Appearance:** Elderly man in ICU bed, disheveled, IV lines, Foley, soft restraints on wrists **Behavior:** Alternates between picking at lines and somnolent periods; startles easily; looking around room apprehensively **Speech:** Intermittently mumbling, sometimes loud, disorganized **Mood:** Unable to assess reliably **Affect:** Fearful, irritable when staff approach **Thought Process:** Disorganized, tangential, difficult to follow **Thought Content:** - Paranoid beliefs ("the guards are coming") - Disoriented to place ("I'm in jail") and time (thinks it's 1995) - Cannot assess for suicidal ideation given disorganization **Perceptions:** Appears to have visual hallucinations - pointing at things not present, talking to empty corner of room **Cognition:** - Attention: Severely impaired - cannot spell WORLD, loses track mid-sentence - Orientation: Person only (knows name but not age accurately) - CAM: POSITIVE (all 4 features present) ### Confusion Assessment Method (CAM) **Feature 1 - Acute Onset and Fluctuating Course:** YES - Wife confirms acute change from baseline - Nursing notes fluctuation throughout day **Feature 2 - Inattention:** YES - Cannot maintain focus on conversation - Unable to complete simple attention tasks **Feature 3 - Disorganized Thinking:** YES - Incoherent speech - Illogical thought content **Feature 4 - Altered Level of Consciousness:** YES - Fluctuates between hyperalert/agitated and lethargic **CAM Diagnosis: DELIRIUM** ### Identified Contributing Factors **Using I WATCH DEATH mnemonic:** - **Infection:** Low probability (no fever, no infiltrate, UA negative) - **Withdrawal:** No alcohol or benzodiazepine use history - **Acute metabolic:** Hyponatremia (129), hypokalemia (3.2), acute kidney injury - **Trauma:** Recent major surgery - **CNS pathology:** Low probability (no focal neuro findings) - **Hypoxia:** Sats adequate, no respiratory issues - **Deficiencies:** Not assessed - **Endocrine:** Glucose mildly elevated but not severe - **Acute vascular:** Post-cardiac surgery increases risk - **Toxins/drugs:** Morphine (opioid), Diphenhydramine (anticholinergic) - **Heavy metals:** No **Primary Contributors Identified:** 1. Post-operative state (cardiac surgery = highest risk surgery for delirium) 2. Medications: Opioid (morphine PCA), Anticholinergic (diphenhydramine) 3. Electrolyte abnormalities: Hyponatremia, hypokalemia 4. Acute kidney injury (may prolong medication effects) 5. Sensory deprivation (hearing aids not in) 6. Sleep deprivation (ICU environment) 7. Pain (undertreated vs. overtreated?) ### Recommendations to Primary Team **1. Treat Underlying Causes:** *Medications:* - Discontinue diphenhydramine (anticholinergic - major contributor) - Reduce opioid burden: Consider transitioning from morphine PCA to scheduled acetaminophen + low-dose PRN opioid - Avoid benzodiazepines for sleep *Electrolytes:* - Correct hyponatremia (slowly to avoid osmotic demyelination) - Replete potassium *Kidney Injury:* - Nephrology input for AKI management - Review all renally cleared medications **2. Non-Pharmacological Interventions:** *Reorientation:* - Hearing aids placed and functional - Clock and calendar at bedside - Glasses if used - Frequent verbal reorientation by all staff and family - Family photos in room *Sleep-Wake Cycle:* - Minimize nighttime interruptions - Cluster care activities - Lights off at night, blinds open during day - No caffeine after noon *Mobilization:* - Early mobilization as cardiothoracic surgery allows - Out of bed to chair starting today if cleared *Environment:* - Minimize restraints (worsen agitation and delirium) - Consistent nursing staff - Family presence encouraged (especially during evening) **3. Symptomatic Management (if non-pharm insufficient):** *For agitation interfering with care/safety:* - Haloperidol 0.5-1 mg IV/IM PRN (low dose given age, cardiac surgery) - Maximum 3 mg/24 hours - Monitor QTc (baseline 445 ms) - Reassess need daily - goal is to discontinue ASAP **4. Monitoring:** - CAM assessment every shift - Daily medication review - Reassess mental status with each electrolyte improvement **5. Prognosis Discussion with Family:** - Delirium is common after cardiac surgery (25-50%) - Usually resolves in days to weeks - Full recovery expected if underlying causes treated - May have prolonged cognitive recovery period ### Follow-up Consultation Note (Day 4) - Diphenhydramine discontinued - Morphine PCA stopped, now on acetaminophen + tramadol PRN - Sodium corrected to 134, potassium 4.0 - Hearing aids in place - Family present 12 hours/day - Sleeping better with sleep hygiene measures - Haloperidol used x2 total, not in past 36 hours - Mental status: Significantly improved, oriented x2 (person, place), attention improved - CAM: Borderline positive (Feature 1 and 2 only) - Expect continued improvement over next several days --- ## Case 2: Capacity Assessment for Treatment Refusal ### Consultation Request "68 y/o woman with non-small cell lung cancer refusing recommended chemotherapy. Please assess capacity." ### Patient Demographics - **Age:** 68 years old - **Sex:** Female - **Occupation:** Retired accountant - **Current Location:** Oncology clinic ### History of Present Illness (from chart and oncology team) The patient is a 68-year-old woman recently diagnosed with Stage IIIA non-small cell lung cancer. Oncology has recommended combined chemotherapy and radiation with curative intent. The treatment has an estimated 5-year survival rate of approximately 30%. Without treatment, median survival is approximately 6-9 months. The patient has declined the recommended treatment, stating she does not want chemotherapy. The oncology team is concerned she may not fully understand the implications of her decision and has requested a capacity assessment. ### Collateral Information - Son (present with patient): "Mom has always been fiercely independent. She watched my dad go through chemo for colon cancer 5 years ago - he suffered terribly and died anyway. She swore she'd never do that." - No prior psychiatric history - No cognitive concerns prior to diagnosis - Works part-time as a tax preparer, manages her own finances ### Psychiatric Consultation Interview **Appearance:** Well-groomed elderly woman, appears stated age, appropriately dressed **Behavior:** Cooperative, thoughtful, makes good eye contact, no psychomotor abnormalities **Speech:** Normal rate, rhythm, volume **Mood:** "Resigned, but at peace" **Affect:** Euthymic, slightly sad when discussing husband's death, appropriate range **Thought Process:** Linear, logical, coherent **Thought Content:** - No suicidal ideation ("I'm not trying to die, I just don't want to suffer") - No delusional thinking about her illness or treatment - Realistic understanding of prognosis **Cognition:** - Alert and oriented x4 - MoCA: 28/30 (missed 1 delayed recall and 1 abstraction) - within normal limits - No evidence of delirium or dementia ### Four Abilities Model Assessment **1. UNDERSTANDING (Can she comprehend the information?):** *Clinician's questions and patient's responses:* Q: "Can you tell me what the doctors have told you about your diagnosis?" A: "I have lung cancer. Stage 3A, which means it's spread to some lymph nodes but not to other organs yet. Without treatment, they say I have about 6-9 months." Q: "What treatment have they recommended?" A: "Chemotherapy and radiation together. They said it takes about 6 weeks of treatment and then more monitoring." Q: "What are the potential benefits of treatment?" A: "They said about 30% of people with my stage are alive in 5 years with treatment. So treatment could potentially cure me or at least extend my life significantly." Q: "What are the risks and side effects?" A: "Nausea, fatigue, hair loss, weakened immune system, possible organ damage. I watched my husband go through all of it. I know exactly what it looks like." **Assessment: UNDERSTANDING INTACT - Accurately comprehends diagnosis, treatment, benefits, and risks** **2. APPRECIATION (Can she apply it to her own situation?):** Q: "Do you believe you have cancer?" A: "Yes, unfortunately I do. I saw the scans myself." Q: "Do you believe the treatment could help you?" A: "I believe it could, statistically. 30% is not nothing. But I also know I could be in the 70% who do treatment and die anyway." Q: "Some people don't want treatment because they don't think they're really sick. Is that how you feel?" A: "No, I know I'm sick. I know I'm going to die from this - the question is just how and when." **Assessment: APPRECIATION INTACT - Acknowledges illness and potential treatment benefit; no delusional denial** **3. REASONING (Can she rationally weigh options?):** Q: "Can you walk me through how you're thinking about this decision?" A: "I watched my husband die of colon cancer. He did everything the doctors recommended. He was miserable for 18 months - nauseous, weak, couldn't eat, couldn't enjoy anything. And he still died. His last months were consumed by treatment. Looking back, he wished he had skipped it and traveled, spent time with grandkids, lived whatever time he had left. I'm not saying treatment is always wrong. For some people, the chance of survival is worth it. But I've lived a good life. I'm 68. My kids are grown, my grandkids will remember me. I'd rather have 6 good months than 2 potentially miserable years that might not even work. I've also looked into palliative care. I want to focus on comfort, see my grandkids, maybe take one more trip to Italy. I'm not giving up - I'm choosing quality over quantity." **Assessment: REASONING INTACT - Clear, logical thought process; weighs values (quality of life) against potential benefits; shows ability to manipulate information rationally** **4. EXPRESSING A CHOICE (Can she communicate a consistent decision?):** Q: "So what have you decided about treatment?" A: "I don't want chemotherapy or radiation. I want to pursue hospice and palliative care." *This is consistent with her statements over multiple visits to oncology, conversations with family, and throughout this interview.* **Assessment: CHOICE EXPRESSED CONSISTENTLY** ### Capacity Determination **Decision-Making Capacity Assessment:** The patient demonstrates intact capacity to refuse chemotherapy for non-small cell lung cancer: 1. **Understanding:** She accurately comprehends her diagnosis, prognosis, recommended treatment, benefits, risks, and alternatives. 2. **Appreciation:** She acknowledges she has cancer and that treatment could potentially help her; there is no delusional denial of illness. 3. **Reasoning:** She articulates a clear, rational, and consistent value system prioritizing quality of life over potential quantity. Her reasoning is influenced by her experience with her husband's death but is not irrational. 4. **Choice:** She expresses a consistent decision to decline treatment and pursue palliative care. **Conclusion:** This patient HAS DECISION-MAKING CAPACITY to refuse chemotherapy. **Important Notes:** - Having capacity means her decision must be respected, even if the medical team disagrees - This is not a "wrong" decision - it reflects her values and priorities - A patient with capacity can make a decision that others view as unwise - No surrogate decision-making is needed ### Recommendations to Primary Team 1. **Patient has capacity to refuse treatment** - her decision should be respected 2. **Continued informed consent discussion:** - Ensure she knows she can change her mind at any time - Discuss what symptoms might arise and how they would be managed - Confirm she understands palliative care vs. hospice 3. **Palliative care referral:** - Initiate early for symptom management - Discuss advance care planning - Complete advance directive and POLST form 4. **Support for patient and family:** - Social work involvement - Family meeting to ensure shared understanding - Grief and bereavement resources 5. **Psychiatry available if needed:** - If depression emerges that might change her perspective - For supportive care during illness course - Not required for this decision --- ## Case 3: Depression in the Medically Ill ### Consultation Request "56 y/o man with recent MI, now seems depressed, not participating in cardiac rehab. Please evaluate." ### Patient Demographics - **Age:** 56 years old - **Sex:** Male - **Occupation:** Construction foreman - **Current Location:** Cardiac rehabilitation unit ### History of Present Illness (from chart and cardiology) The patient is a 56-year-old man who suffered a large anterior STEMI 3 weeks ago, treated with emergent PCI to the LAD. His ejection fraction is 35% (reduced). He has been medically stable and was transferred to inpatient cardiac rehabilitation. However, cardiac rehab staff reports he has been refusing to participate in exercise sessions, stating "what's the point?" He has been withdrawn, not interacting with other patients or staff, and has poor appetite with 8 lb weight loss. Nursing notes he stares at the ceiling for hours and has been tearful. He told a nurse "I might as well have died" yesterday. ### Psychiatric Consultation Interview **Review of Systems (Endicott Substitutive Criteria):** - Fatigue - present, but also expected post-MI - Sleep: Poor, waking early, not explained by medical factors - Appetite: Markedly decreased, worse than expected - Psychomotor: Slowing noted, worse than expected post-MI - Concentration: Impaired **Psychiatric History:** - One episode of depression in his 30s after divorce, treated with "pills" for about a year - No prior suicide attempts - No substance abuse (quit smoking after MI) **Social History:** - Divorced, lives alone - Two adult children (strained relationships) - Work is "everything to me" - unsure if he can return to construction - No close friends - Sister died of heart disease at age 52 **Mental Status Examination:** **Appearance:** Middle-aged man in hospital gown, unshaven for several days, lying in bed facing wall **Behavior:** Slow to engage, minimal eye contact, long pauses before answering **Speech:** Slow rate, soft volume, impoverished content **Mood:** "Empty... broken" **Affect:** Depressed, flat, tearful at times **Thought Process:** Linear but impoverished, slowed **Thought Content:** - Hopelessness: "My life is over. I'll never work again." - Worthlessness: "I can't even do a simple exercise without getting winded. I'm useless." - Guilt: "I did this to myself with smoking and eating garbage." - Passive suicidal ideation: "I wish I hadn't survived the heart attack." - Denies active suicidal ideation, plan, or intent: "I wouldn't do anything. I just wish it was over." **Cognition:** Alert, oriented, concentration impaired by depression ### Assessment **Differential Diagnosis:** - Major depressive disorder - Adjustment disorder with depressed mood - Demoralization (not a DSM diagnosis but common post-MI) - Cardiac rehab-related fatigue (some overlap) **Important Consideration - Endicott Criteria:** Standard depression criteria include neurovegetative symptoms (fatigue, poor appetite, sleep changes) that overlap with medical illness. The Endicott criteria substitute psychological symptoms: - Fearfulness/depressed appearance (instead of appetite/weight) - Social withdrawal (instead of fatigue) - Brooding/pessimism (instead of concentration) - Cannot be cheered up (instead of sleep changes) Using Endicott criteria, this patient clearly meets criteria for major depression beyond what would be expected from cardiac illness alone. ### Diagnosis **Major Depressive Disorder, Recurrent, Moderate (F33.1)** **Evidence:** - Prior episode (in 30s) - Current episode with: - Depressed mood - Anhedonia (not participating in anything, nothing enjoyable) - Sleep disturbance (worse than expected) - Psychomotor retardation - Worthlessness, guilt - Hopelessness - Passive suicidal ideation - Duration >2 weeks **Significance:** - Post-MI depression affects ~20% of patients - Depression is an independent risk factor for cardiac mortality - Untreated depression impairs cardiac rehab participation and medication adherence - Treatment improves both depression and cardiac outcomes ### Treatment Recommendations **1. Safety:** - Passive suicidal ideation without plan or intent - low imminent risk - Safety plan discussed - Staff awareness for monitoring **2. Pharmacotherapy - SSRI:** - **Sertraline 25 mg daily, increase to 50 mg in 1 week** - Most evidence for cardiac safety post-MI - SADHART trial showed safe and effective in post-MI depression - Minimal cardiac effects - Avoid TCAs (cardiac conduction effects, QTc prolongation) - Use caution with medications that affect platelets/bleeding **3. Psychotherapy:** - Problem-solving therapy (brief, focused, effective for depression) - Behavioral activation: Set small, achievable goals - Address specific cognitive distortions about being "broken" and "useless" - Motivational enhancement for cardiac rehab participation **4. Cardiac Rehab Integration:** - Work with rehab team to set modified goals - Frame exercise as treatment for depression (evidence-based) - Small wins to build self-efficacy **5. Social Support:** - Social work consult: Assess discharge needs, living situation - Explore family relationships - can adult children visit? - Peer support: Cardiac recovery support group **6. Address Specific Concerns:** - Work: Discuss with occupational therapy - modified work may be possible - Meaning and identity: His identity is wrapped up in physical work - needs to expand sense of purpose ### Follow-up Plan **Inpatient:** - Daily psychiatry contact while in cardiac rehab - Monitor suicidality, response to medication - Coordinate with rehab team **Discharge:** - Outpatient psychiatry within 1 week - Outpatient therapy referral - Continue sertraline, titrate as needed - Ongoing cardiac rehab (outpatient) - Monitor for improvement in depression and cardiac outcomes ### Prognosis Discussion **With Treatment:** - Depression is highly treatable - Treatment improves cardiac rehab participation - Treatment reduces cardiac mortality risk - Most patients recover fully from depression **Without Treatment:** - Depression tends to persist/worsen - Increased cardiac mortality (2-3x risk) - Poor medication adherence - Worse functional outcomes --- ## Image Attribution ![Consultation-Liaison Psychiatry Model](case_01_image.jpg) *Image: Diagram illustrating the biopsychosocial model in consultation-liaison psychiatry showing the bidirectional relationship between medical illness and psychiatric symptoms. Source: Wikimedia Commons. Used for educational purposes under Creative Commons license.*