Informed consent: Is your patient competent to refuse treatment?

Current Psychiatry. 2009 April;08(04):33-43

April 1, 2009|Psychiatry

Adult patients with psychotic disorders are not automatically or always incompetent.

¹ In this model of shared decision-making, the clinician reveals information material to the decision, and the patient helps the clinician understand the circumstances that make him or her prefer 1 treatment over another.^1,18

By engaging in ongoing informed consent, you may achieve greater gains within the therapeutic alliance and reduce the risk of liability.¹⁹ Where uncertainties are related to treatment, share these ambiguities as an aspect of informed consent, especially when the patient plays an active role in treatment.⁴ Similarly, an expanded informed consent process may be needed when:

proposed treatments are particularly risky
several treatment alternatives could be acceptable and effective
evidence supports opposing views of a treatment’s effectiveness.^4,20

Table

Using informed consent to build a therapeutic alliance

Use the informed consent dialogue to establish trust and openness with patients while demonstrating respect for patient autonomy Allow patients to share their values and concerns as part of the risk/benefit analysis Talk with patients to understand their preconceived ideas about their illnesses and to seek a common understanding of the illness and its prognosis, with and without treatment

Use the informed consent dialogue to establish trust and openness with patients while demonstrating respect for patient autonomy
Allow patients to share their values and concerns as part of the risk/benefit analysis
Talk with patients to understand their preconceived ideas about their illnesses and to seek a common understanding of the illness and its prognosis, with and without treatment

CASE CONTINUED: A question of competence

Mr. D is calm in his discussions with the psychiatrist, and the information she presents does not seem to cause him further harm. Thus, the emergency and therapeutic privilege exceptions do not eliminate the need for an ongoing informed consent process at this time.

Mr. D has a factual understanding of the risks and benefits of the recommended antipsychotic and is able to express a consistent choice about starting this treatment. He lacks, however, an ability to appreciate his situation and has difficulty manipulating information rationally. Overall, he has deficits in aspects of his decision-making competence, which could signal the need for an exception to obtaining informed consent.

Clinical Point

Talk with the patient to seek a common understanding of the illness and its prognosis, with and without treatment

The psychiatrist should continue to build an alliance with Mr. D as she works with him toward accepting treatment. Meeting with him regularly, trying to understand his concerns, and trying to help him understand how his symptoms may be interfering with his functioning can help build the alliance. If he continues to show competence-related deficits, she could pursue guardianship or other legal avenues to address his ongoing inability to provide informed consent. This approach would allow for a legally authorized mechanism to administer treatment to this patient.

Related resources

Pinals DA, Appelbaum PS. The history and current status of competence and informed consent in psychiatric research. Isr J Psychiatry Relat Sci. 2000;37(2):82-94.
American Medical Association. Legal issues/patient physician relationship topics. www.ama-assn.org/ama/pub/physician-resources/legal-topics.shtml.

Disclosure

Dr. Pinals reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

References

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