Training Geriatric Psychiatry Fellows in the Medicolegal Aspects of Psychiatric Consultation in the Nursing Home

Article excerpt

Accredited fellowship training programs in geriatric psychiatry are required to address ethical and legal issues pertaining to mental health in older adults, and to provide clinical experiences that enable trainees to develop competencies in long-term care consultation. The growing number of criminal offenders with mental illness and other disabling conditions that require long-term care, along with comprehensive federal regulations that affect mental health care in nursing homes, is creating a more urgent public health need to train psychiatrists with specific competencies in patient care, interpersonal skills and communication, and systems-based practice as they apply to medicolegal aspects of psychiatric consultation in the nursing home setting. This article reviews legal and regulatory information that is pertinent to training fellows in the care of elderly nursing home residents with mental illness or behavioral problems. It describes several aspects of the Geriatric Psychiatry Fellowship Training Program at the University of Pennsylvania that promote development of skills in geriatric psychiatry consultation in nursing homes.

KEY WORDS: Forensic psychiatry, geriatric psychiatry, psychiatric consultation, nursing homes.

Since 2003, the Accreditation Council on Graduate Medical Education (ACGME) has required that the curricula of clinical fellowship programs in geriatric psychiatry address "the ethical and legal issues especially pertinent to geriatric psychiatry, including competence, guardianship, right to refuse treatment, wills, informed consent, elder abuse, the withholding of medical treatments, and federal legislative guidelines governing psychotropic drug prescription in nursing homes" (ACGME, 2003). The subspecialty program requirements also emphasize attainment of skills as a consultant, and specifically mandate "consultative experience in chronic care facilities" (ACGME, 2003). Despite these longstanding training requirements, there are no standardized, comprehensive curricula for teaching forensic aspects of geriatric psychiatry; and to our knowledge, there is no published guidance on the preparation of psychiatrists to serve as consultants on the medicolegal aspects of long-term care for older adults.

The challenge for geriatric training is one of growing public health significance, because long-term care facilities continue to experience a rise in the admission of criminal offenders with histories of mental illness who also require specialized medical care (Cohen, Hays, & Molinari, 2011). They include (but are not limited to) registered sex offenders, parolees, and inmates transferred by correctional authorities. While policies and criteria for admission vary between facilities and states, practices for risk assessment of offenders, and education of staff about behavioral management to protect themselves and other vulnerable residents, while preserving the rights of the offenders, are less well understood. Moreover, policies and practices developed by facilities must conform with federal regulations that protect the rights of individuals in long-term care facilities.

In this article, we describe several aspects of the Geriatric Psychiatry Fellowship Training Program at the University of Pennsylvania (Penn) that are specifically designed to promote the development of competencies in patient care, interpersonal skills and communication, and systems-based practice as they apply to medicolegal aspects of psychiatric consultation in the nursing home setting. We review legal and regulatory information that is pertinent to training fellows in the care of elderly nursing home residents with mental illness or behavioral problems. For heuristic purposes, we illustrate with vignettes from a case involving an elderly patient with chronic psychiatric and medical problems requiring longterm care, whose history of a sexual offense and whose current behaviors complicate his management and raise ethical and legal dilemmas for the nursing home staff and administrators. …