LAKE, Justice.
The defendant’s contentions on this appeal are that the trial court erred: (1) In requiring the defendant to plead to the indictment and to stand trial thereon; (2) in admitting into evidence, over objection, the testimony of Nurse Bass, Attendant Williams and Dr. Parmelee concerning statements made by the defendant to them at the Wayne Memorial Hospital; (3) in denying the defendant’s motion for a directed verdict of not guilty; and (4) in its instructions to the jury concerning insanity as a complete defense to the charges and in its failure to instruct the jury concerning the defendant’s mental condition with reference to the matters of premeditation and deliberation. In all of these, the crucial factor is the defendant’s mental capacity. The test of sufficient mental capacity in each of these areas is different from the test to be applied in the other three.
If there was no error in the trial court with reference to these matters, the imposition of the several sentences to imprisonment for life was proper, these offenses having been committed prior to our decision in State v. Waddell, 282 N.C. 431, 194 S.E. 2d 19. The defendant concedes in his brief that his exceptions and assignments of error directed to the denial of his motion in arrest of judgment, to the denial of his motion to set aside the verdict and to the entering and signing of the judgments are formal and present no additional question for review. We turn, therefore, to a consideration of mental capacity as related to his four contentions.
The test of a defendant’s mental capacity to stand trial is whether he has, at the time of trial, the mental capacity to comprehend his position, to understand the nature and object of the proceedings against him, to conduct his defense in a rational manner, and to cooperate with his counsel to the end that any available defense may be interposed. State v. Jones, 278 N.C. 259, 179 S.E. 2d 433; State v. Propst, 274 N.C. 62, 161 S.E. 2d 560; State v. Sullivan, 229 N.C. 251, 49 S.E. 2d 458; Strong, [566]*566N. C. Index 2d, Criminal Law, § 29; 21 Am. Jur. 2d,. Criminal Law, § 65. When, as here, this question is properly raised before the defendant pleads to the indictment, it should be determined prior to the commencement of the trial, as was done 'ih' this instance. State v. Propst, supra, at page 69. It may' be ‘determined by the trial court with or without the aid of a jury; State v. Propst, supra, at page 68. When the court, as here, conducts the inquiry without a jury, the court’s findings of fact, if supported by evidence, are conclusive on appeal. State v. Squires, 265 N.C. 388, 144 S.E. 2d 49. The fact that, at an earlier; date, a judge had found the defendant was, at that time, lacking.in capacity to stand trial does not prevent the same or a different judge from conducting another hearing and reaching a different conclusion at a later date. See, State v. Midyette, 270 N.C. 229, 154 S.E. 2d 66.
In this instance, there was ample expert medical testimony to support the trial court’s finding that the defendant was competent to plead to the charges against him and to stand trial. The fact that the defendant had to be given medication periodically during the trial, in order to prevent exacerbation of his mental illness by the tensions of the courtroom, does not require a finding that he was not competent to stand trial when, as here, the undisputed medical testimony is that the medication did not have the effect of dulling his mind and that the specified dosage was adequate to keep his mental illness in remission. Ur. Maynard testified that, in his opinion, the defendant, at the time the case was called for trial, had the capacity to comprehend his position, to understand the nature and object of the proceedings against him and to cooperate with his counsel to the end that any available defense might be interposed. He further testified that, in his opinion, the defendant, at the time the case, was called for trial, had the capacity to remember what happened on the night of the alleged offenses and could intelligently discuss those events with his counsel, if he would. Under these circumstances, there was no error in requiring the defendant to plead to the indictments and to stand trial on the charges against him.
The statements by the defendant to Nurse Bass, Dr. Par-melee and Attendant Williams in the emergency room of the Wayne Memorial Hospital were confessions that he had killed his wife and the four small children. “A confession is an acknowledgment in express words by the accused in a criminal case of the truth of the,guilty fact.charged or of some essential [567]*567part of it.” Wigmore on Evidence, 3d Ed, § 821; State v. Hamer, 240. N.C. 85, 81 S.E. 2d 193. At the time these confessions of the defendant were made, he was not in custody and was not under police interrogation. Miranda v. Arizona, 384 U.S. 436, 86 S.Ct. 1602, 16 L.Ed. 2d 694, is inapplicable. Nevertheless, to be admissible in evidence against him, the confessions of the defendant to the hospital attendants must have been made voluntarily and understandingly. State v. Gray, 268 N.C. 69, 150 S.E. 2d 1; State v. Whittemore, 255 N.C. 583, 122 S.E. 2d 396; State v. Hamer, supra.
For a confession to have been made understandingly, the defendant, at the time of making it, must have had the requisite mental capacity. In State v. Whittemore, supra, at page 587, Justice Rodman, speaking for the Court, said: “If the accused has sufficient mental capacity to testify, he has sufficient mental capacity to confess.” The test of the mental competency of a witness to testify is his capacity to understand and to relate, under the obligation of an oath, a fact which will assist the jury in determining the truth with respect to the ultimate facts at issue. Strong, N. C. Index 2d, Witnesses, § 1. The trial court’s finding that a confession was voluntarily and understandingly made is conclusive on appeal if there is evidence in the record to support it. State v. Fox, 277 N.C. 1, 24, 175 S.E. 2d 561; State v. Gray, supra.
In this instance, the trial judge found that, at the time the defendant made the statements in question, he had a sufficient understanding to apprehend the obligation of an oath, he was capable of giving a correct account of the matters which he had seen or heard with respect to the deaths of his wife and children and he made the statements in question freely, voluntarily and understandingly.
There was evidence that while the defendant was in the emergency examining room at Wayne Memorial Hospital he was, at frequent intervals, nervous and shaking and, from time to time, stared off into space. One who had, but a few hours previously, brutally killed his wife and four tiny children would naturally exhibit signs of nervousness and emotional stress. These manifestations by the defendant in the emergency room of the hospital fall far short of a conclusive demonstration of his lack of memory and understanding sufficient to make his confession inadmissible as a matter of law.
[568]*568The attending physician, the nurse and the hospital attendant who heard the statements testified that, in his or her opinion, the defendant, when making them, was in his right mind, could comprehend what he was saying, responded normally to questions, knew and understood the meaning of what he was saying and was capable of relating recent facts stored in his memory. Dr.
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LAKE, Justice.
The defendant’s contentions on this appeal are that the trial court erred: (1) In requiring the defendant to plead to the indictment and to stand trial thereon; (2) in admitting into evidence, over objection, the testimony of Nurse Bass, Attendant Williams and Dr. Parmelee concerning statements made by the defendant to them at the Wayne Memorial Hospital; (3) in denying the defendant’s motion for a directed verdict of not guilty; and (4) in its instructions to the jury concerning insanity as a complete defense to the charges and in its failure to instruct the jury concerning the defendant’s mental condition with reference to the matters of premeditation and deliberation. In all of these, the crucial factor is the defendant’s mental capacity. The test of sufficient mental capacity in each of these areas is different from the test to be applied in the other three.
If there was no error in the trial court with reference to these matters, the imposition of the several sentences to imprisonment for life was proper, these offenses having been committed prior to our decision in State v. Waddell, 282 N.C. 431, 194 S.E. 2d 19. The defendant concedes in his brief that his exceptions and assignments of error directed to the denial of his motion in arrest of judgment, to the denial of his motion to set aside the verdict and to the entering and signing of the judgments are formal and present no additional question for review. We turn, therefore, to a consideration of mental capacity as related to his four contentions.
The test of a defendant’s mental capacity to stand trial is whether he has, at the time of trial, the mental capacity to comprehend his position, to understand the nature and object of the proceedings against him, to conduct his defense in a rational manner, and to cooperate with his counsel to the end that any available defense may be interposed. State v. Jones, 278 N.C. 259, 179 S.E. 2d 433; State v. Propst, 274 N.C. 62, 161 S.E. 2d 560; State v. Sullivan, 229 N.C. 251, 49 S.E. 2d 458; Strong, [566]*566N. C. Index 2d, Criminal Law, § 29; 21 Am. Jur. 2d,. Criminal Law, § 65. When, as here, this question is properly raised before the defendant pleads to the indictment, it should be determined prior to the commencement of the trial, as was done 'ih' this instance. State v. Propst, supra, at page 69. It may' be ‘determined by the trial court with or without the aid of a jury; State v. Propst, supra, at page 68. When the court, as here, conducts the inquiry without a jury, the court’s findings of fact, if supported by evidence, are conclusive on appeal. State v. Squires, 265 N.C. 388, 144 S.E. 2d 49. The fact that, at an earlier; date, a judge had found the defendant was, at that time, lacking.in capacity to stand trial does not prevent the same or a different judge from conducting another hearing and reaching a different conclusion at a later date. See, State v. Midyette, 270 N.C. 229, 154 S.E. 2d 66.
In this instance, there was ample expert medical testimony to support the trial court’s finding that the defendant was competent to plead to the charges against him and to stand trial. The fact that the defendant had to be given medication periodically during the trial, in order to prevent exacerbation of his mental illness by the tensions of the courtroom, does not require a finding that he was not competent to stand trial when, as here, the undisputed medical testimony is that the medication did not have the effect of dulling his mind and that the specified dosage was adequate to keep his mental illness in remission. Ur. Maynard testified that, in his opinion, the defendant, at the time the case was called for trial, had the capacity to comprehend his position, to understand the nature and object of the proceedings against him and to cooperate with his counsel to the end that any available defense might be interposed. He further testified that, in his opinion, the defendant, at the time the case, was called for trial, had the capacity to remember what happened on the night of the alleged offenses and could intelligently discuss those events with his counsel, if he would. Under these circumstances, there was no error in requiring the defendant to plead to the indictments and to stand trial on the charges against him.
The statements by the defendant to Nurse Bass, Dr. Par-melee and Attendant Williams in the emergency room of the Wayne Memorial Hospital were confessions that he had killed his wife and the four small children. “A confession is an acknowledgment in express words by the accused in a criminal case of the truth of the,guilty fact.charged or of some essential [567]*567part of it.” Wigmore on Evidence, 3d Ed, § 821; State v. Hamer, 240. N.C. 85, 81 S.E. 2d 193. At the time these confessions of the defendant were made, he was not in custody and was not under police interrogation. Miranda v. Arizona, 384 U.S. 436, 86 S.Ct. 1602, 16 L.Ed. 2d 694, is inapplicable. Nevertheless, to be admissible in evidence against him, the confessions of the defendant to the hospital attendants must have been made voluntarily and understandingly. State v. Gray, 268 N.C. 69, 150 S.E. 2d 1; State v. Whittemore, 255 N.C. 583, 122 S.E. 2d 396; State v. Hamer, supra.
For a confession to have been made understandingly, the defendant, at the time of making it, must have had the requisite mental capacity. In State v. Whittemore, supra, at page 587, Justice Rodman, speaking for the Court, said: “If the accused has sufficient mental capacity to testify, he has sufficient mental capacity to confess.” The test of the mental competency of a witness to testify is his capacity to understand and to relate, under the obligation of an oath, a fact which will assist the jury in determining the truth with respect to the ultimate facts at issue. Strong, N. C. Index 2d, Witnesses, § 1. The trial court’s finding that a confession was voluntarily and understandingly made is conclusive on appeal if there is evidence in the record to support it. State v. Fox, 277 N.C. 1, 24, 175 S.E. 2d 561; State v. Gray, supra.
In this instance, the trial judge found that, at the time the defendant made the statements in question, he had a sufficient understanding to apprehend the obligation of an oath, he was capable of giving a correct account of the matters which he had seen or heard with respect to the deaths of his wife and children and he made the statements in question freely, voluntarily and understandingly.
There was evidence that while the defendant was in the emergency examining room at Wayne Memorial Hospital he was, at frequent intervals, nervous and shaking and, from time to time, stared off into space. One who had, but a few hours previously, brutally killed his wife and four tiny children would naturally exhibit signs of nervousness and emotional stress. These manifestations by the defendant in the emergency room of the hospital fall far short of a conclusive demonstration of his lack of memory and understanding sufficient to make his confession inadmissible as a matter of law.
[568]*568The attending physician, the nurse and the hospital attendant who heard the statements testified that, in his or her opinion, the defendant, when making them, was in his right mind, could comprehend what he was saying, responded normally to questions, knew and understood the meaning of what he was saying and was capable of relating recent facts stored in his memory. Dr. Maynard, the psychiatric expert who had the defendant in his care before and at the trial, testified that, in his opinion, the defendant was “in contact with reality” when he made these statements. All the evidence is that the statements were made spontaneously by the defendant to persons who knew nothing of and were not interrogating him about the subject matter of his statements prior to his making them. There was no error in the admission of the testimony concerning these confessions by the defendant.
G.S. 8-53 specifically authorizes the trial judge to compel disclosure of a statement otherwise within the physician-patient privilege when necessary to the proper administration of justice. The judge so found and ordered with respect to the státéments made to Nurse Bass and Attendant Williams and, thereupon, the defendant withdrew his objection as to Dr. Parmalee’s testimony.
A motion for a directed verdict of not guilty has the same effect as a motion for judgment of nonsuit. State v. Britt, 285 N.C. 256, 204 S.E. 2d 817. On such motion the evidence for the State is taken to be true, conflicts and discrepancies therein are resolved in the State’s favor and it is entitled to every reasonable inference which may be drawn from the evidence. State v. Cutler, 271 N.C. 379, 156 S.E. 2d 679. The basis for the defendant’s motion for a directed verdict of not guilty was that, at the time the alleged offenses were committed, the defendant was insane and, therefore, not criminally responsible. Obviously, the evidence was sufficient otherwise to require the submission to the jury of the charge of murder in the first degree in each case. There was evidence that each victim was bound before he or she was killed. Four of the victims were children six years of age and under. Each death was caused by a brutal assault. Brutality in a slaying is evidence of intent to kill, not, per se, a basis for finding the defendant insane. State v. Reams, 277 N.C. 391, 402, 178 S.E. 2d 65; State v. Stanley, 227 N.C. 650, 44 S.E. 2d 196; State v. Bynum, 175 N.C. 777, 783, 95 S.E. 101.
[569]*569Over and over again, this Court has said that the test of insanity as a defense to a criminal charge is the capacity to distinguish between right and wrong at the time of and in respect to the matter under investigation. State v. Humphrey, 283 N.C. 570, 196 S.E. 2d 516; State v. Jones, supra; State v. Benton, 276 N.C. 641, 174 S.E. 2d 793; State v. Rogers, 275 N.C. 411, 168 S.E. 2d 345, cert den., 396 U.S. 1024; State v. Atkinson, 275 N.C. 288, 167 S.E. 2d 241, reversed on death penalty only, 403 U.S. 948; State v. Spence, 271 N.C. 23, 155 S.E. 2d 802, reversed on another point, 392 U.S. 649; State v. Creech, 229 N.C. 662, 51 S.E. 2d 348; State v. Swink, 229 N.C. 123, 47 S.E. 2d 852. As Justice Branch, speaking for the Court, said in State v. Humphrey, supra, “North Carolina, as well as many other jurisdictions, has steadfastly refused to recognize the ‘irresistible impulse doctrine’ as a test of criminal responsibility.”
In State v. Duncan, 244 N.C. 374, 93 S.E. 2d 421, Justice Parker, later Chief Justice, speaking for the Court, said:
“To determine the issue as to whether the defendant was insane at the time of the alleged commission of the offense evidence tending to show the mental condition of the accused both before and after the commission of the act, as well as at the time of the act charged, is competent, provided the inquiry bears such relation to the person’s condition of mind at the time of the alleged crime as to be worthy of consideration in respect thereto. It would be impracticable to limit the evidence to such condition at the exact time.”
In State v. Atkinson, supra, at page 313, we said that a witness, who was an expert in the field of psychiatry, was competent to relate to the jury his opinion as to the defendant’s knowledge of right and wrong at the time of the alleged offense even though the witness did not observe the defendant on the precise date of the alleged offense.
In the present instance, Nurse Bass, who observed the defendant closely at the Wayne Memorial Hospital approximately 24 hours after his wife and children were killed, testified that, in her opinion, he then seemed to be in his right mind. In the opinion of Attendant Williams, the defendant knew right from wrong at the time they were talking; i.e., approximately 24 hours after the alleged offenses. In the opinion of Dr. Parmelee, who attended him in the emergency room, the defendant then knew right from wrong, although he was suffering then [570]*570from paranoid schizophrenia and, assuming that the killings occurred while the defendant was under a delusion that his children were from outer space, the defendant nevertheless knew the difference between right and wrong and was able to control his behavior and adhere to the right and he acted according to his own free will in killing his wife and children. Dr. Maynard, an expert psychiatrist, testified that the defendant did have the capacity to distinguish between right and wrong at the time of and in respect to the matter under investigation. In view of this evidence, it is clear that the question of the defendant’s insanity, as a'defense to the charges of murder, was for the jury under proper instructions by the court and the motion for a directed verdict of not guilty was properly overruled.
The court’s charge to the jury contained the following:
“Now, in this case as to each of the bills of indictment you will be required to enter one of four verdicts. You can find the defendant guilty of first degree murder; you can find the defendant guilty of second degree murder; you can find the defendant not guilty by reason of insanity and you can find the, or you can find the defendant not guilty. That is you will have to consider five different bills of indictment, five different charges and enter one of those four verdicts as to each charge.
[Here follow correct instructions as to the elements of first degree murder and second degree murder and the burden of proof with reference thereto.]
“Now, the defendant has the burden of proving that he was insane. However, unlike the State which must prove the defendant’s guilt beyond a reasonable doubt, the defendant must only prove his insanity to your satisfaction. Therefore, I charge that if you’re satisfied from the evidence that the defendant at the time of the alleged crime, and as a result of a mental disease or defect, although intelligent, either did not know the nature and quality of his act or did not know that it was wrong, you must find him not guilty.
* * *
“Now, if on December 1, 1971, you should find and find beyond a reasonable doubt that the defendant did commit the acts which I’ve described for you: first degree [571]*571murder or as to second degree murder, if you are satisfied that on that date the defendant by reason of his mental disease or defect did not know the nature or quality of his act or did not know the difference between right and wrong at the time and in relation to the matters under investigation, then you would find the defendant not guilty by reason of • insanity.”
In these instructions we perceive no error. Where, as here, there is evidence justifying the submission to the jury of the question of insanity as a defense to the charge, we believe a better r procedure would be to submit to the jury as the first issue for their consideration, “Was the defendant (at the time of the alleged offense), by reason of a defect of reason or disease of jthe mind, incapable of knowing the nature and quality of the act which he is charged with having committed, or if he did know this, was he, by reason of such defect or disease, incapable of distinguishing between right and wrong in relation to such act?” An affirmative answer to that issue would end the case. If the jury answers that issue in the negative, it should then proceed to determine the defendant’s guilt or innocence of the offense charged just as if the defendant were a person of normal mental capacity. The failure to submit such an issue to the jury specifically, or to give it the priority here suggested, is not, however, ground for a new trial.
The defendant’s final contention is that the court failed to charge the jury on all substantial features of the case arising on the evidence and failed to apply the law to the evidence.
There was no error in the failure of the court to include in its. recapitulation of the evidence the statement by Dr. Peter, contained in the discharge summary by which the defendant was returned by Cherry Hospital to the Superior Court for trial on 2 March 1972. Dr. Peter did not testify before the jury but Dr. Maynard, who did testify, said, on cross-examination by the defendant, that he, in arriving at his own expert opinion as to the ability of the defendant to distinguish right from wrong at the time of the alleged offenses, had available, and took into consideration, Dr. Peter’s opinion as set forth in the discharge summary. That statement of Dr. Peter, put before the jury by the defendant’s cross-examination of Dr. Maynard, was that the defendant knows right from wrong but “at the time of the alleged offense wm not able to apply his knowledge of right and wrong and the alleged offense was the product of his mental [572]*572illness.” (Emphasis added.) This was the expression of an opinion that the defendant, by reason of his mental disease, acted under an irresistible impulse, notwithstanding his ability to distinguish between right and wrong with reference to such act. Since an irresistible impulse is not a defense under the law of this State, as above noted, it was not error for the court to fail to refer to this statement by Dr. Peter in his recapitulation of the evidence.
The defendant says the court also erred in its failure to instruct the jury that it should consider the evidence of the defendant’s mental disease on the question of premeditation and deliberation.
It is well established that to convict a defendant of murder in the first degree, when the killing was not perpetrated by one of the means specified by G.S. 14-17 and was not committed in the perpetration of or attempt to perpetrate a felony, the State must prove beyond a reasonable doubt that the killing was with premeditation and deliberation. G.S. 14-17; Strong, N. C. Index 2d, Homicide, § 4, and the numerous cases therein cited. It is also well established that a specific intent to kill is a necessary ingredient of premeditation and deliberation. State v. Baldwin, 276 N.C. 690, 700, 174 S.E. 2d 526; State v. Robbins, 275 N.C. 537, 169 S.E. 2d 858; State v. Propst, supra, at page 71. It follows, necessarily, that a defendant who does not have the mental capacity to form an intent to kill, or to premeditate and deliberate upon the killing, cannot be lawfully convicted of murder in the first degree, whether such mental deficiency be due to a disease of the mind, intoxication, as in State v. Alston, 214 N.C. 93, 197 S.E. 719, or some other cause. It does not follow, however, that there was reversible error of omission in the charge of the trial court in the present case.
The jury, by its verdict, has established that the defendant, at the time of the alleged offenses, had the mental capacity to know right from wrong with reference to these acts. This distinguishes the present case from cases such as State v. Alston, supra, dealing with intoxication as a defense. That finding, supported as it is by ample evidence, is conclusive on appeal, irrespective of a contrary opinion by the defendant’s mother and irrespective of inferences which might reasonably be drawn from the State’s evidence as to the defendant’s appearance and manner when first observed by the police officer and when being [573]*573examined in the emergency room of the Wayne Memorial Hospital.
We may take judicial notice of the well known fact that a dog, a wild animal or a completely savage, uncivilized man may have the mental capacity to intend to kill and patiently to stalk his prey for that purpose. The law, however, does not impose criminal responsibility upon one who has this level of mental capacity only. For criminal responsibility it requires that the accused have, at the time of the act, the higher mental ability to distinguish between right and wrong with reference to that act. It requires less mental ability to form a purpose to do an act than to determine its moral quality. The jury, by its verdict, has conclusively established that this defendant, at the time he killed his wife and the four little children, had this higher level of mental capacity. It necessarily follows that he had the lesser, included capacity. The jury also determined that he did, in fact, premeditate and deliberate upon the intended killings. It made these determinations in the light of proper instructions as to what constitutes premeditation and deliberation. Premeditation and deliberation do not require a long, sustained period of brooding. State v. Fountain, 282 N.C. 58, 70, 191 S.E. 2d 674; State v. Reams, supra.
No error.
Justices Copeland and Exum did not participate in the hearing or decision of this case.