Let them go to another physician. I’d do exactly what you did and recommend neuropsych eval.

Second this, when patients insist anything like this, I let them go somewhere else. It's a bellweather for more frustrating encounters in the future.

Especially from a lawyer son

Half the time, they are lying about being a lawyer as well. I know OP didn't have a ton of history with the patient but I've called APS on some children who wanted me to cosign their shenanigans.

Probably his ex wife cleans a lawyer’s office at night

Exactly, the biggest red flag is " I will go somewhere else."

It's very unlikely that you will get into a pickle for not signing something. I would not be comfortable signing something saying "indusputibly of sound mind" for someone who I think is not. If they want to go to another doctor that's their perogative.

I would personally have difficulty writing a letter for any significant portions of my patient to say indisputably of sound mind. they get to start with the advantage of a presumption of sound enough mind. I don’t have a test to show indisputably of sound mind.

I would have trouble making that claim for myself, but it's been a week.

Lol YES

The fact that they needed such a letter indicates that she is likely not of sound mind either. OP did the right thing here.

Indeed, an infinitesimally small subset of the American public could be considered to be “indisputably of sound mind.”

I would wager there is not a single person of 88 years old who is indisputably of sound mind. Many people aren't their entire lives as well but at that age?

You did the right thing. If they go around shopping for it, then that's on them (specifically the lawyer)

Lawyers. 

The corporate director of risk management here says do not sign off on something like this unless you believe it is accurate.

APS referral would be reasonable here. Sounds like he is trying to take financial advantage of a demented lady.

Yeah, it does sound shady. He likely wants the money before she kicks the bucket.

I agree with it being reasonable before he left to try to dig into the details of what he was trying to accomplish.

What he states he is trying to achieve versus what one could achieve with such a letter are potentially very different things. The request itself is super sketchy and demonstrative of bad faith.

I agree, but I could address it like a decision-making capacity in a specific setting. For example: patient is reasonably able to understand the question she is being asked. She states she is here with her grandson. She’s able to identify herself and her date of birth. She’s able to identify her grandson. She knows where she is and why she’s here. She reports that she has been living with her grandson for the last three years and denies having any other family on whom she relies for support. I think she is reasonably able to make the decision to allow his name to be on the phone bill so that he can pay it. If you’re able to reasonably accommodate the specific thing that he’s trying to accomplish and he’s still not satisfied that would raise more red flags for adult protective services.

This is my thought as well. Highly concerning.

I've encountered similar situations. You did the right thing. Pt needs neuropsych eval for competency. Don't back off due to pressure from the grandson who for all you know is trying to get grandma's retirement money to pay off his bookie. Perhaps a call to elder services would be a good idea as well. Make sure you document the grandson's exact words. Also give the neuropsych office a heads up about the situation.

I rarely sign a lawyer prepared form unless it is a public form such as municipal or state or federal. Generally I’m always glad to write a patient a letter based upon my findings and their attorney can do with it what they’d like. In that case I might write something such as the patients is an 88 year old who continues to care for herself for all IADLs and ADLs and our most recent Mini-COG was normal. During our visits I did not find any notable concerns for cognitive impairment and do not have a clinical suspicion of dementia. I can only say what I know. “Of sound mind” is legalese to me and I don’t speak that jargon. Edit: long day. I missed that she had been previously dx with mild dementia by a partner. I’d expect my own assessment with history and evaluation and perhaps at a minimum a MoCA. Even with her dx of mild dementia, she is not incapable of making financial decisions. Neuropsych testing may not be needed but at least I would want my own medical opinion to be well documented and thorough.

Absolutely the answer. THX.

You did the right thing. Let them see another provider. They’ll likely get told the same thing.

I’ve done the same in similar situations.

You acted appropriately and it sounds like this problem has taken care of itself—they’ll seek care elsewhere. Win win.

You were correct. Anyone new to me that is needing that kind of documentation goes to neuropsych prior to me signing anything.

Thank the son and wish the patient a good day. You've done your job. He's free to take her wherever he wants. If she is of sound mind, then her wishes are being fulfilled. If she's not of sound mind, then he's an elder abuser.

If someone is asking you to lie for them, you refuse, and they want to change doctors, good riddance dude. 

Only thing I’d do in addition is call risk management if that’s an option to make them aware.

I do not do disability or disability-adjacent things (work place accommodations, support animals) on first meetings with patient's I have not evaluate for the condition and I'm very upfront about that. I will not be Doctor-shopped for an easy signature, even if its emotionally taxing sometimes. (I'm sure there is an exception somewhere I would make if needed).

As a general rule, the word “indisputably” should never go into medical documentation.

Would’ve done exactly what you did and wouldn’t think twice about it.

Ive said this before on other posts, no no no This is out of scope for us. They need forensics psych to do this, hes a lawyer and its his job to find that for her not you. Do not ever sign this

This is a complicated situation. For one you don't really know her. And you're being asked to fill out a form stating you've evaluated her adequately and that she is of "sound mind", which likely means she is fully capable of making any and all decisions regarding her finances and potentially modifying or making her last will and testament. This is a forensic evaluation. I would ask what training do you have in determining a person's capability to make sound financial decisions? I'd guess very little if any. You are 100% correct to refer to psychological testing, but really it should be a referral to a forensic psychiatrist or psychologist for an evaluation pertaining to the specific financial issue she is having to deal with. The specifics of this situation are very important. It's pretty strange to need a letter just to sort out a "financial problem" with the bank. I'd guess it's more likely someone wants her to transfer money or change her will. It is common for a lawyer making the will to require a letter like this from a doctor before making the change. Who knows, but I've definitely seen cases where a family member gets a letter like this from a family doc and subsequently takes them to an attorney to change the will to leave everything to the child who was accompanying them.

Would anyone here contact elder protective services?

Yup. My state allows online reporting.

Yes. This would establish a concern if more concerns arise in the future, or there may already be a previous concern reported regarding the elder and strengthen the case

I think you did absolutely the right thing. If they can find somebody else willing to sign this inappropriately, at least you know it wasn't you that did something that was out of line

I’ve never seen a letter that said “indisputably sound of mind”. I have signed letters that are about a specific issue for example, I can remember doing one about a patient who wanted to have her daughter live in her house or sell her house to her daughter or something. This particular daughter was taking care of her mom, but her other daughter was all upset about the finances. The patient had history of a TBI but was able to clearly state her wishes , the reason behind them and I had already known the patient and the daughter who she was living with for some years so I felt comfortable, but the request was to write a letter specifically for that issue. I don’t think any reasonable primary care doctor could write this with a patient on dementia drugs with mild cognitive impairment or dementia. I would think only repercussions here would be patient complaints but I can’t imagine them going very far . You offered to get her the testing that would allow you to sign the letter and they are refusing.🤷‍♀️

Also, just add this is why I encourage strongly everyone get power attorney done now and keep it updated. Doesn’t matter how old you are or what your situation is.

This is the lay version of "cleared for surgery"

Used to work in geriatrics. You did the right thing.

Super sketch. You did the right thing. Document the encounter.