THE IMPORTANCE OF DECISION MAKING CAPACITY FOR PATIENTS AND PHYSICIANS: TWO CASES ASHLEY D. GRIMSHAW, MD MELISSA ARTHUR, PHD

THE IMPORTANCE OF DECISION MAKING CAPACITY FOR PATIENTS AND PHYSICIANS: TWO CASES ASHLEY D. GRIMSHAW, MD MELISSA ARTHUR, PHD

CASE 1 30 year old pregnant female G2P0010 at 38w0d with history of paranoid schizophrenia, substance abuse, bipolar depression, and late-seeking prenatal care presents to OB triage with abdominal pain and emesis for a few hours.

PHYSICAL EXAM T 97.4 F, HR 84, BP 177/111 General: Erratic behavior, yelling, in and out of bed, ripping off BP cuff. Abdomen: Soft, gravid, nontender, no palpable contractions GU: unable to assess cervix, thick vaginal discharge without vaginal bleeding on external exam Extremities: no edema FHR 140 by doppler

CASE PROGRESSION Benzodiazepines and pain medication administered as patient a danger to herself and staff. Blood pressure persistently elevated hypertensive protocol initiated. Lab results confirm preeclampsia Magnesium Sulfate infusion and plans for induction started. FHR becomes category III and persists despite resuscitative efforts Cesarean section recommended. 2 ½ hours pass while attempt to convince patient to consent to procedure, despite the fact that she has again become erratic and is ruminating on having Foley catheter removed. Physician in charge states a psychiatrist is required to judge if a patient is without decision making capacity. Nurse manager arrives and refutes the need for psychiatry. Patient s parents sign consent. C- section completed. Infant pale, limp, apneic, without respiratory effort. APGARS 2, 6, 7.

CASE 2 77 year old Female with history of dementia, past alcohol abuse and HTN presents from LTC with dyspnea, found to have severe anemia. Patient hospitalized twice 5 months prior with anemia requiring transfusion secondary to GI and vaginal bleeding. Patient refused colonoscopy or endometrial biopsy at that time.

PHYSICAL EXAM T 99.2 F, BP 135/60, HR 80, RR 15, SpO2 95% RA General: Alert, oriented to person only GI: abdomen soft, non tender, FOBT negative GU: no obvious vaginal bleeding on external exam

CASE PROGRESSION ED: Transfusion 2 units PRBCs, with patient signing the consent form herself. On initial evaluation by inpatient team, clear that patient unable to demonstrate understanding, appreciation, or reasoning in regards to situation and deemed to lack decision making capacity. Per records, previous admitting team consulted psychiatry who had deemed patient lacking capacity. Patient s daughter, out of state, did not want to take decisions away from her mother. Did agree to make decisions through hospitalization and declined further work up of bleeding. Discharged back to LTC facility. Patient s care team at LTC agreed to begin ethics case in regards to setting up health care proxy as family previously declined to do so at multiple previous meetings.

THE RESEARCH PATIENTS Studies have shown the prevalence of incapacity in the following: Depression Inpatients: 20% Medicine Inpatients: 26% Nursing Home Residents: 44% Schizophrenia Inpatients: 50% Alzheimer Disease: 54% Severe Learning Disability: 68% Strong relationship between capacity and cognition, but cognition is not a substitute for capacity. MMSE < 16: high likelihood of incapacity MMSE > 24: decreased likelihood of incapacity PRACTITIONERS In a pooled analysis physicians failed to recognized incapacity in 58% of patients independently determined to lack capacity. A study where doctors reviewed videos of capacity assessments and made their own capacity determinations achieved an agreement rate no better than chance. A study of 302 medical inpatients estimated that ~48% were incompetent, however the clinical team identified only one quarter of that group. 3-25% of psychiatric consultation requests in hospitals involve questions about competence. Providing physicians with specific legal standards to guide judgement significantly increases interrater agreement, as does having a specific set of questions to use.

TEACHING POINTS Most physicians lack formal training in evaluating capacity. Capacity includes 4 core abilities: Expressing a choice Understanding Appreciation Reasoning Capacity is temporal and situational. Evaluations should occur in the contest of a specific decision that must be made. Any licensed physician can make the determination of incapacity. Capacity can be optimized. Health care practitioners often give more weight to patient s final decision than the process used to come to that decision. Consent obtained from incompetent patient is invalid and without a substitute decision maker treatment provided in a non-emergent situation is considered treating without consent.

QUESTIONS?

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