Ethical Issues: The Patient’s Capacity to Make Medical Decisions
by Y. Sher, MD and S. Lolak, MD; http://www.psychiatrictimes.com; 11/28/14
Although not always formally competent in ethics, consultation-liaison (C/L) psychiatrists and psychosomatic medicine physicians who practice in general hospitals frequently see cases laden with ethical questions. In a 2006 survey of members of the Academy of Psychosomatic Medicine, virtually all respondents reported that management of bioethical dilemmas had a significant effect on the work; capacity evaluation and informed consent made up nearly all the issues. In fact, evaluation with the patient’s decisional capacity is one of the most common consultation requests in acute hospital settings. In such situations, the main team along with other hospital staff (eg, case manager, social worker) often look to psychiatry to deliver the recommendations that could affect the patient’s treatment course and outcomes.
This article gives a practical framework that can guide C/L psychiatrists through solving problems of capacity and informed consent.
The 4 principles
The 4 cardinal principles of biomedical ethics—autonomy, beneficence, nonmaleficence, and justice—are widely accepted as standard ethical principles in medicine. The conflict between autonomy and beneficence/nonmaleficence often contributes to distress among health care professionals, as well as patients in addition to their families, and quite often manifests in psychiatric consultations for evaluation of the patient’s chance to make medical decisions as well as to refuse recommended treatment. This is especially true if the clinician feels strongly concerning the need to intervene to maximize outcomes however the patient disagrees. Although the clinician turns to capacity evaluations to cope with his or her very own discomfort and distress, the underlying moral dilemma stems from the conflict between a patient’s autonomy and also the physician’s paternalism.
In assessing capacity to supply informed consent, keep in mind that informed consent comprises 3 critical elements: providing information (ie, full disclosure), decisional capacity, and voluntarism capacity (ie, capacity to make a decision, totally free of coercion).
Appelbaum outlined decisional capacity and it is 4 standards:
• Ability to communicate a choice
• Ability to understand information required for the specific decision at hand
• Ability to appreciate the implications and significance in the provided information or the choice being made
• Ability to reason by weighing and comparing options and also consequences in the potential decision
Wright and Roberts advocate the use with the “Four Topics Method” to help with ethical decision-making strategy for patients in a very medical setting. With this algorithm, each case is analyzed through 4 aspects:
• Medical indications
• Patient preferences (and also the patient’s decisional capacity)
• Quality-of-life issues
• Contextual features or external factors that may affect the individual’s care
In addition, Wright and Roberts recommend Drane’s “sliding scale” model, which modulates the threshold to determine the patient’s decisional capacity according to risk to benefit ratio of the decision, to aid with the analysis. For example, the greater the risk associated while using patient’s treatment refusal, the low the threshold for deeming the sufferer as lacking decisional capacity.
Two typical cases that may arise are presented in the event vignettes. They describe relevant ethical dilemmas as well as their formulations, and demonstrate the way a C/L psychiatrist can work through each case using the “Four Topics Method.”
Ms A is really a 73-year-old with diabetes, hypertension, and end-stage renal failure. She is receiving hemodialysis and it has had above-the-knee right lower extremity amputation. She is delivered to the hospital after a fall. This will be the third similar presentation for the hospital during the past 2 months.
The evaluation reveals malnutrition, dehydration, and early-stage bedsores. Ms A is evaluated by a social worker and a physical therapist; both recommend a skilled nursing facility as the most appropriate placement to be with her. However, the individual fervently refuses this option, and psychiatry is termed in to evaluate her capability to make decisions.
Ms A is available to be alert and fully engaged, with bright affect and a linear and goal- oriented thought processes. She explains she has been independent her entire life and that they values her independence a lot. She states that she “would rather die than live elsewhere rather than her own house.” She understands that they is in poor health but is willing to engage additional services at home to deal with any health concerns. If that isn’t enough, she “would rather go back home and suffer the results than be placed in the nursing home.”
The C/L psychiatrist finds that although the hospitalist and associated clinicians believe that Ms A’s decision is poor and places her at high-risk for recurrent complications and readmission, Ms A has the ability to make decisions regarding her discharge. The team is recommended to work closely using the patient to optimize her supports in your house.
This case demonstrates a common conflict from your patient’s autonomy as well as the physician’s duty and drive to offer beneficence. Physicians often feel overprotective of patients while confronting what they feel are unsafe decisions. They begin to question the sufferer’s decisional capacity. Paternalism exists when a physician believes which he knows better than the person what is in the individual’s desires and places the sufferer’s medical good most importantly of all. However, it is the physician’s responsibility to respect the sufferer’s values and to understand the impact of medical and psychosocial interventions, keeping in mind the individual’s particular cultural/attitudinal context. It is important to always closely work with all the patient to get the best solution, set up work is distressing, because the physician feels that the individual is making a bad decision.
In other cases, the individual’s capacity may indeed be impaired, especially when there is evidence of impairment of “executive autonomy” (from cognitive, functional, or physical deficits). This is often seen in the management of patients with chronic conditions, especially when they are elderly. In such cases, treatment nonadherence as well as home safety issues may arise.
The elderly person with multiple medical problems and mild cognitive dysfunction who can tell the doctor what she should do to stay safe and stay healthy but frequently ends up in a healthcare facility because she forgets to take her medicines and contains problems taking proper herself can be a typical case. While the person can indicate her preferences and usually has good understanding in the plan, there exists clear evidence that executive function impairment interferes with her capacity to complete the needed tasks. The part of “voluntariness” comes into play as a consequence with the internal impairments that inhibit goal-directed actions, thus rendering the individual incapacitated.
Mrs B, a 55-year-old with end-stage heart failure who's a pacemaker/implantable cardioverter defibrillator (ICD), is admitted to the hospital for failure to thrive. Since receiving her pacemaker/ICD a year ago, Mrs B is here to believe that device is harming her. She reports significant pain from your device and wants it removed. In fact, she repeatedly tells her cardiologists she wants to hold the pacemaker/ICD taken out. She would want to switch to alternative treatment approaches to treat her heart failure.
Mrs B became so passionate about her beliefs which it caused significant fallout between her and her husband and kids who opposed her views. She firmly believes which they want to harm her, and he or she has asked them to move out. A C/L psychiatrist is called to evaluate Mrs B’s decision-making capacity.
Mrs B insists how the only treatment for her distress is the removal of the device, and she's not ready to consider or discuss every other options. The psychiatrist finds that they has delusional disorder; she is offered an antipsychotic, which she declines.
Mrs B is considered to have, essentially, 3-4 months to live. Her cardiologists believe turning off the ICD will be appropriate and in reality preferable to avoid unnecessary and highly distressing shocks (in addition to unnecessarily potentially prolonging/preventing natural death). However, the removal with the device is contraindicated because from the potentially harmful results of surgery; moreover, the pacing activity continues to be helping to make the sufferer comfortable.
The C/L psychiatrist decided that Mrs B lacks capacity to make medical decisions and that her loved ones are an appropriate surrogate decision maker. Mrs B’s family consents to turning from the ICD device, nevertheless the pacemaker is left intact. Because of the poor prognosis and poor reply to antipsychotics, it really is thought not to become in the person’s best interests to seek psychiatric hospitalization and/or administration of antipsychotics against Mrs B’s will.
This case demonstrates the complexity of an capacity evaluation. While on the surface the individual appears delusional and it is tempting to dismiss the individual’s preferences as completely irrational, it is important to elucidate and take into consideration the patient’s long-standing beliefs and values to generate the most appropriate decision to get a patient who lacks decisional capacity.
In Mrs B’s case, discussions along with her family made it clear she had actually had long-standing beliefs regarding minimal interventions and holistic approaches. She consented towards the pacemaker/ICD implantation when she became very sick a year ago, but then her previously held beliefs solidified into such rigid structures with false premises they became delusional.
However, it had been also important to take the individual’s long-standing beliefs and values into account while making decisions on her behalf. Although currently her values crystallized into psychotic beliefs, her lifelong-held values supported minimal intervention. Thus, together with her impending death, it turned out thought most appropriate to minimize interventions and to arrange for home hospice care, making her comfort and dignity essential. This translated into turning off the ICD device, minimizing the number of medications for her heart condition, and never pursuing psychiatric interventions.
As elegantly stated inside a paper by Naik and colleagues, “Effective treatment planning may be exercised through a dynamic, iterative technique of identifying patients’ limitations, tailoring appropriate interventions, and supplanting deficits of executive autonomy with adequate supports. This approach can occur inside chronic longitudinal setting in addition to at discharge planning after a serious intervention.”
Psychiatrists who practice in medical settings will often be asked to deliver not only psychiatric recommendations but also suggestions on the ethical issues involving medical/surgical patients. Familiarity with the core ethical principles and ethical decision-making strategies (Sidebar) can help the clinician deliver high-quality care grounded inside the principles of medical ethics.