Decisional Capacity (I).

Shad­ow­fax presents a case study in applied ethics and asks:

What would you do if you were the doc­tor in this sit­u­a­tion (or the administrator/ethicist/judge called to offer guid­ance)? Would you pro­vide sup­port­ive care and allow him to die, or would you vio­late his express wishes and intu­bate him?

Physi­cians often call psy­chi­a­trists for con­sul­ta­tion in sim­i­lar, though less acute, clin­i­cal sit­u­a­tions. These requests are called “assess­ments of deci­sional capac­ity”. Psy­chi­a­trists do not have a spe­cial license to make these assess­ments. Any physi­cian can make a deter­mi­na­tion of deci­sional capac­ity. Many doc­tors ask psy­chi­a­trists to per­form these assess­ments, how­ever, as (1) psy­chi­atric con­di­tions can affect a patient’s deci­sional capac­ity and (2) psy­chi­a­trists have more expe­ri­ence than other physi­cians in assess­ing deci­sional capacity.

Deci­sional capac­ity” refers to a person’s abil­ity to make a deci­sion for a spe­cific clin­i­cal issue. This issue is usu­ally related to treat­ment. After assess­ment, physi­cians can opine whether some­one pos­sesses or lacks deci­sional capac­ity for some­thing specific:

  • He has the deci­sional capac­ity to refuse treat­ment for his prostate cancer.”
  • She does not have the deci­sional capac­ity to refuse surgery for her infected leg.”

Com­pe­tency”, which is often con­flated with “capac­ity”, is a legal term. Only judges in courts of law have the power to deem some­one “incom­pe­tent” and thus unable to make deci­sions for themselves.

Appel­baum and Grisso pub­lished an impor­tant paper that pro­vides a four-point rubric to assess deci­sional capac­ity. (At only four pages, it is a short, high-yield arti­cle.) Most psy­chi­a­trists apply this rubric when assess­ing deci­sional capac­ity in med­ical set­tings. If the patient can­not ful­fill any one of the four cri­te­ria, the patient prob­a­bly lacks deci­sional capac­ity. As an exer­cise, let’s apply these cri­te­ria to the case that Shad­ow­fax presents.

The ques­tion: Does the patient have the deci­sional capac­ity to refuse intu­ba­tion and mechan­i­cal ven­ti­la­tion for treat­ment of his lung injuries?

1. Can the patient com­mu­ni­cate a choice? This choice must be clear and remain sta­ble over time. If the patient can­not (or will not) com­mu­ni­cate a choice, the inter­viewer can­not assume that the patient has the abil­ity to make a deci­sion. (Con­sider one extreme: Some­one who is in a coma.) If the patient repeat­edly changes his choice, this has prac­ti­cal impli­ca­tions: A med­ical team and patient agree to launch Plan A. Right when Plan A is about to unfold, the patient refuses it. The team can­cels Plan A, but then the patient says he wants Plan A. This is a problem.

The case patient appears to be com­mu­ni­cat­ing a con­sis­tent choice (refus­ing intubation).

2. Does the patient have an under­stand­ing of rel­e­vant infor­ma­tion? Does the patient under­stand what the diag­no­sis means? the risks and ben­e­fits of pro­posed treat­ment? the risks of ben­e­fits of alter­na­tive treat­ments (which includes doing noth­ing)? Again, con­sider an extreme: If a patient does not under­stand that surgery involves the cut­ting of skin, that patient can­not make informed deci­sions related to surgery.

The case patient was able to com­ment that “refus­ing intu­ba­tion would lead to his death.” He was appar­ently “unable to, or chose not to, artic­u­late any rea­son that he did not want to be intu­bated”. From the avail­able infor­ma­tion, we do not know if this patient under­stood that he had a lung injury. (Was his choice based solely on the unpleas­ant thought of some­one shov­ing a tube down his throat?) We also do not know if he under­stood the risks and ben­e­fits of intu­ba­tion and mechan­i­cal ventilation.

3. Does the patient have an appre­ci­a­tion for the cur­rent cir­cum­stances and con­se­quences? This may sound sim­i­lar to #2, but there is a notable dif­fer­ence: This ques­tion asks if the patient under­stands the con­di­tion and treat­ment options as it applies to him. Patients with demen­tia, for exam­ple, might know the course and out­come of demen­tia after wit­ness­ing the con­di­tion in a rel­a­tive, but may not rec­og­nize that their own cog­ni­tive func­tion is impaired. Sim­i­larly, con­sider a pro­ce­dure that results in death 50% of the time. If a patient says, “I’m not like every­one else! There’s absolutely no chance I will die!”, he lacks the abil­ity to make informed deci­sions for him­self for this spe­cific issue.

It appears that the case patient rec­og­nized that if he refused intu­ba­tion, he would die. We do not know if he under­stood that he him­self had a lung injury and how avail­able treat­ment might help (or hurt) him. (As an aside, one could argue that the patient has already demon­strated ambiva­lence about death and dying. Most peo­ple who have made the com­mit­ment to die gen­er­ally will not go to an emer­gency room “on three con­sec­u­tive days for sui­ci­dal ideation and non-life-threatening sui­ci­dal gestures”.)

4. Can the patient manip­u­late infor­ma­tion in a ratio­nal man­ner? This asks if some­one can apply suf­fi­cient logic to his cur­rent sit­u­a­tion. Another extreme: If some­one has the unshak­able con­vic­tion that all sur­geons implant micro­scopic, par­a­sitic aliens into patients dur­ing oper­a­tions, that patient lacks the abil­ity to make informed deci­sions related to surgery.

From the avail­able infor­ma­tion, it is unclear if the case patient could manip­u­late infor­ma­tion in a ratio­nal man­ner for this spe­cific sit­u­a­tion. We do not know the rea­sons why he did not want to be intu­bated. One rea­son could have been his stated desire to die. We do not know if he believed that he would have access to end­less opi­ates in the after­life. We do not know if he felt over­whelm­ing guilt for dam­ag­ing a tree and thus believed that he deserved to die. It may be unfair to assume that he can­not manip­u­late infor­ma­tion in a ratio­nal man­ner sim­ply because he could not state rea­sons for refus­ing intu­ba­tion. How­ever, it is also unfair to assume that he can manip­u­late infor­ma­tion in a ratio­nal man­ner in the absence of data.

You may now rec­og­nize the amount of time and infor­ma­tion needed to ren­der an opin­ion about deci­sional capac­ity. (Fur­ther­more, I per­son­ally believe that any­one ren­der­ing these opin­ions should con­sult with col­leagues for qual­ity con­trol. Our per­sonal biases affect our judg­ments. These extra dis­cus­sions con­sume more time.) As a result, this process often can­not occur in acute med­ical situations.

Given the lim­ited infor­ma­tion (due pri­mar­ily to the acu­ity of the sit­u­a­tion), it is not clear if the patient had the deci­sional capac­ity to refuse intu­ba­tion and mechan­i­cal ven­ti­la­tion for treat­ment of his lung injuries. One might lean more towards the opin­ion that he lacked deci­sional capac­ity, since he did not pro­vide a con­vinc­ing argu­ment that he under­stood the rel­e­vant infor­ma­tion or appre­ci­ated the sit­u­a­tion and the consequences.

In addi­tion to the rubric described above, some authors argue for a “slid­ing scale” in deci­sional capac­ity. If the patient in Shadowfax’s case was intu­bated, the physi­cians likely applied this “slid­ing scale”. I will describe it in fur­ther detail in a later post. For a pre­view, look over the com­ments in Shadowfax’s post.