Is your patient making the ‘wrong’ treatment choice?

• clarify the question (such as, “Does Mrs. Z have the capacity to refuse dialysis?”)
• give an opinion about whether the patient does or does not have capacity and why.

When sharing of opinions was studied at institutions trying this idea, C/L teams agreed with the primary teams’ initial impression of patients’ capacity 80% of the time.⁴ Most consults occurred because the patient was refusing an intervention the primary team felt was “essential,” or the patient and primary team disagreed on code status. At our institution, anecdotal evidence shows that if the primary team spends a few minutes asking screening questions, the C/L service and primary team agree on the patient’s capacity >90% of the time.

Table 1

Primary team capacity evaluation: 5 W’s

Tips for the psychiatrist

C/L psychiatrists are usually asked to evaluate capacity in complicated cases, such as when the:

• family disagrees with the patient’s decision
• patient changes his mind several times
• patient has a formidable psychiatric history.

Determining capacity requires that you assess the patient’s ability to communicate choices, understand and retain information about his condition and proposed treatment, appreciate likely consequences, and rationally manipulate information (Table 2).⁷

You can often gauge a patient’s attitude the moment you walk into his or her room. Those who feel insulted or defensive about being evaluated by a psychiatrist say things like:

• “I’m not crazy; I don’t need to talk to you.”
• “I think you need to evaluate my doctors, not me.”
• “Why is it so hard to believe that I’m ready to die? You can’t change my mind. Get out!”

To put the patient at ease, consider an inoffensive introduction such as: “My name is Dr. Y and I’m one of the psychiatrists who work here. I’m often called by the primary team to help explain the pros and cons of the various treatments we can provide to you. I’m not here to change your mind; I just want to make sure you are aware of all your options.”

Table 2

Psychiatry C/L service capacity evaluation

Is it ever ok not to assess capacity?

In rare situations, informed consent does not need to be pursued and neither does capacity. Informed consent occurs when a capable patient receives adequate information to make a decision and voluntarily consents to the proposed intervention.⁸ Informed consent is not required in emergency, patient waiver, or therapeutic privilege situations.^8,9

Emergency exception is permitted if the patient lacks the capacity to consent and the harm of postponing therapy is imminent and outweighs the proposed intervention’s risks. These cases are usually life-threatening situations in the emergency department, such as when a patient suffers severe physical trauma in a motor vehicle accident and is unable to communicate. Although capacity cannot be established, patients are taken immediately to the operating room.

If a patient with capacity refuses emergent treatment, however, the treating physician cannot override the patient’s wishes simply because it is an emergency. For example:

Mrs. L, age 32, lost several liters of blood during a complicated vaginal delivery. Her obstetrician felt she needed an emergent blood transfusion to avoid further medical complications. Mrs. L—a Jehovah’s Witness—refused the transfusion because of her religious beliefs. She was deemed capable of making this decision, and the transfusion was deferred.^8-10