Day Six After the Stroke: The Man Who Says No to Everything
Mr. D is a 61-year-old right-handed warehouse supervisor, day 6 after a left middle cerebral artery infarct. He has dense right hemiparesis and severe nonfluent aphasia: he produces 'no' and occasional single words, follows no commands, and has an NG tube for dysphagia. NIHSS fell from 14 to 9. He says 'no' to every request - food, physical therapy, repositioning, transfer to inpatient rehabilitation - and has twice pulled at his feeding tube. His daughter, the documented health care agent, says he was 'never a depressed man,' but staff report he cries during therapy and when she leaves. Medications: metoprolol, labetalol, atorvastatin, enoxaparin. No prior psychiatric history. The primary team asks whether he is depressed, whether he can refuse rehabilitation, and whether they may treat him over his objection.
1. The team asks: is he depressed, and can we start an SSRI today? How do you evaluate mood in a man who cannot answer a questionnaire?
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Start by reframing. The most probable acute problem is not depression but delirium plus a comprehension deficit. A man who pulls at an NG tube and says no to everything is showing fluctuating engagement and motor restlessness, not necessarily low mood. The first instrument is the CAM and a chart review across shifts, not the PHQ-9.
- Delirium screen: assess attention (tracking, blink to threat), sleep-wake reversal, motor activity, hallucinations. Hunt causes: aspiration pneumonia, urinary retention, constipation, pain, hypoxia, electrolytes, and the new-onset renal or hepatic change. Labetalol and metoprolol are minor contributors; do not stop them on speculation.
- Discard verbal scales. With a nonfluent aphasia, self-report items are invalid and a 'no' cannot be scored. Use an observational proxy measure (for example the SADQ-H or the Aphasic Depression Rating Scale) only as a screen, never as a diagnosis.
- Distinguish three things that look alike: post-stroke emotionalism (brief, stimulus-triggered, incongruent crying - common and treatable with an SSRI but not the same as MDD); apathy/abulia from frontal damage (reduced initiation without dysphoria); and true MDD (sustained anhedonia, worthlessness, guilt, persistent sleep and appetite change, functional loss beyond the stroke).
- Six days is too early. Post-stroke depression peaks over the first months. Record observations now; diagnose only when the delirium has cleared and symptoms persist roughly two weeks with neurovegetative features.
If an SSRI is ultimately indicated, sertraline is a reasonable first choice - few anticholinergic effects, modest QT effect. Avoid tricyclics and paroxetine. Watch sodium and bleeding risk (he is on enoxaparin). Nonpharmacologic care matters now: pain control, sleep hygiene, orientation, speech therapy, and having the daughter at meals.
2. How do you assess capacity to refuse inpatient rehabilitation when yes/no output is unreliable? What supports do you request?
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Capacity is decision-specific and risk-relative. The decision here is where he goes next and whether he participates in therapy. It matters, but it is lower-stakes than refusing surgery and partially reversible - a trial of rehabilitation can be revisited.
Step 1: Establish whether 'no' is a communication. Test the reliability of his yes/no channel with ten known-answer questions ('Are you in a hospital?' 'Is your name Mr. D?'). If he answers fewer than about eight correctly, his 'no' cannot be read as a preference - it may be perseveration or the only syllable he can produce. This is not the same finding as 'he refuses.'
Step 2: Supported communication. Ask speech-language pathology for an augmentative evaluation the same day. Use a picture board, large-print two-option written choices, one question at a time, extra processing time, and repeat across two sessions with two different examiners. Comprehension in Broca aphasia is often worse than it appears; have the team teach back the plan rather than lecture once.
Step 3: If the channel truly fails, he cannot demonstrate the first capacity element (communicating a choice). The decision then moves to his daughter as health care agent, exercising substituted judgment with the team. That is an expression failure, not a global declaration of incompetence.
Step 4: Practical recommendations. Ask the physiatrist for a time-limited trial of rehabilitation rather than a binary placement decision; involve the daughter in the meeting; document the method (questions asked, supports used, who observed). Advise against a guardianship petition at day six - it is premature and often unnecessary.
3. He pulls at his NG tube and refuses PT. What do you recommend regarding treatment over objection, restraints, and medication?
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First, treat the delirium, not the behavior. Tube-pulling is a symptom. Look for the reversible cause before anyone orders a sedative: aspiration, constipation, retention, pain, positioning, hunger, thirst, a dry or irritated throat, hypoxia. Correct those and much of the agitation resolves.
Least restrictive sequence:
- Continuous 1:1 supervision, daughter or sitter at the bedside, frequent redirection, secure the tube, offer ice chips and oral care, structured day/night lighting, and mobilization as able.
- Mittens or a soft splint before any four-point restraint. Restraints are an emergency measure with a time-limited order and documented reassessment - never a staffing solution.
- If pharmacologic treatment is necessary for safety, use the lowest dose for the shortest time: quetiapine 12.5–25 mg at night with ECG/QTc surveillance, or trazodone for sleep. Avoid benzodiazepines unless there is a withdrawal syndrome. Typical antipsychotics after stroke carry excess mortality and extrapyramidal risk; if haloperidol is unavoidable use small doses and document the rationale.
Treatment over objection is permissible only if he lacks capacity for this specific decision, the treatment is clearly in his interest (aspiration and malnutrition are real harms), the least restrictive means is used, the health care agent is engaged, and it is documented and time-limited with planned reassessment. That is different from overriding a competent refusal. If the family and team disagree, request an ethics consultation early.
Tell the team plainly: the aim is restored participation, not compliance. Reassess daily, and revisit the goals-of-care conversation with the daughter - what would he have accepted before the stroke?