So I saw this new article on decisional capacity assessment I recently got in my email from the Primary Care Companion to the Journal of Clinical Psychiatry (JCP). It has a fresh angle on the issue which highlights the differences in approach to this skill between internists and psychiatrists. Just for fun, I ran it by our new psychiatry consult mascot, who is struggling along so far without a name.
Dr. Amos: Hey you, what do you think of this blog post “Assessing Patients’ Capacity to Refuse Medical Care”? It refers to an article the author co-wrote on the same subject.
Mascot: My name is not “Hey you.”
Dr. Amos: Fine, what is your name?
Mascot: I have memory impairment. You gotta remember I’m from the late Jurassic Period.
Dr. Amos: What on earth is that lump under you, a turd or an egg?
Mascot: What is “earth”? And it’s an egg. My latest ultrasound says it’s a boy.
Dr. Amos: Getting back to the article, I was wondering if you had an opinion on Dr. Tunzi’s view that there’s an important difference of opinion between psychiatrists and internists regarding decisional capacity, specifically to refuse medical care?
Mascot: What? Nothing about capacity to consent?
Dr. Amos: I never get called about that.
Mascot: Why the heck not? Anyway, what I hear on the street is that the gist of these papers is that psychiatrists tend to give patients the benefit of a doubt and allow patients to refuse care as long as they can show a basic understanding of and have a plan for meeting basic needs. On the other hand, internists basically challenge patients who want to leave against medical advice to a knife fight.
Dr. Amos: Come on, it’s not like that at all!
Mascot: OK, actually they expect a lot more detailed knowledge from patients about their medical illness and the consequences of refusing medical care which can entail a lot of suffering or death. By the way, it’s close to my lunchtime. Got any ferns with atomic chipotle?
Dr. Amos: Not hardly, that stuff looks like cigar butts.
Mascot: Hmmm; remember I weigh about 20 tons and have a long whip-like tail.
Dr. Amos: In the Land Before Time, sure. Bring it on now. Getting back to decisional capacity, what makes for the big difference between internists and psychiatrists on this issue?
Mascot: It’s a frame of reference thing according to Tunzi and Spike. I would use hand gestures for emphasis at this juncture, but I don’t have any. However, I can read which will astonish most humans because you have a bias that dinosaur brains are tiny.
We believe this difference in assessing capacity is a reflection of psychiatric and adult medicine physicians’ different experiences of the health care world. Because psychiatrists frequently interact with the legal system in competency hearings, because most behavioral illness is chronic and fluctuates over time, and because the physiologic consequences of psychiatric illness are rarely irreversible (beyond acute suicidal or homicidal behavior), psychiatrists are generally reluctant to remove decision-making power from patients. While the process of psychiatric consultation often facilitates patients’ ability to understand their illness in a general way—especially regarding social consequences—asking psychiatrists to specifically evaluate medical illness decision-making capacity is often frustrating, as their frame of reference is the mental health system and the courts.
In contrast, because adult medicine physicians face acute medical problems that do not fluctuate but frequently deteriorate without treatment, they are generally reluctant to allow patients to suffer the ill effects of what they perceive to be harmful, irreversible medical decisions. While adult medicine physicians are taught to beware of paternalism, asking them to respect psychiatric patients’ self-determination is often frustrating, as their frame of reference is the intensive care unit and the morgue.
Dr. Amos: That was nicely done. Can you tell me what we should do to resolve our differences?
Mascot: The authors suggest getting an ethics consult. Hey, you got something on your face, dude.
Dr. Amos: That’s called a nose, as opposed to a snout, which you have.
Mascot: Like a I said, I weigh about 20 tons…
Dr. Amos: Are there alternatives to getting an ethics consultation which can take a few days. The typical psychiatric consultation for decisional capacity assessment sometimes results in the consultant finding the patient pulling on his coat and moving rapidly toward the front door.
Mascot: Talking to the patient’s regular primary care doctor or a family member can settle a lot of scores–sort of like a long whip-like tail. And there happens to be a way to integrate an ethics summary into the typical psychiatric consultation. Even an internist could do it.
Dr. Amos: Careful.
Mascot: No really, it’s the University of Washington Ethics 4 Boxes Tool. Most medical students are familiar with it.
Dr. Amos: So this is a decision support tool. Can it be made into an electronic health record smartphrase that we could use in Epic?
Mascot: A smartphrase in an EHR is a species of oxymoron. On the other hand, I’m a species of Apatosaurus, a deceptively clumsy looking reptile. In fact, “Apatosaurus” means “deceptive reptile.”
Dr. Amos: That reminds me. Were you ever on the To Tell the Truth game show?
Mascot: Are you kidding? Kitty Carlisle was way before my time!
Dr. Amos: You know, sometimes psychiatric consultants are asked to get psychiatric hold orders on patients with medical illness who demand to leave the hospital against medical advice. That seems pertinent to this issue.
Mascot: Now that’s a matter I can really get my chisel-like teeth into. I saw this article by a guy named Mossman (who wears really ugly bow ties!) in a March 2013 issue of Current Psychiatry. The bottom line is–don’t do it unless the patient has a psychiatric illness that is substantially interfering with decisional capacity.
Dr. Amos: And what would be wrong with it?
Mascot: Although I hope that the following list doesn’t violate fair use, I do weigh about 20 tons:
- Once you get a hold order you have to have a secure psychiatric unit to which to transfer the patient–the med-surg unit is not appropriate.
- The patient has to have a mental illness requiring involuntary psychiatric hospitalization.
- A psychiatric hold lets you temporarily detain a patient; it doesn’t allow you to force medical treatment.
- If a doctor gets a hold from a magistrate or judge in good faith, he or she is immune from later accusations of malpractice or false imprisonment.
Dr. Amos: Well I guess that about wraps it up–except for your name.
Mascot: “Your Highness” will do for now–I weigh about 20 tons and have a long…
Dr. Amos: Thank you, Your Highness. Your chipotle and ferns have arrived.
Tunzi, M., MD (2015). Assessing Patients’ Capacity to Refuse Medical Care. Let’s Talk Blog, Psychiatrist.com. 2015. Date accessed 4/30/2015.
Tunzi, M., MD, and J. P. Spike, PhD (2015). Assessing Capacity in Psychiatric Patients With Acute Medical Illness Who Refuse Care. Prim Care Companion CNS Disord. 16. Date accessed 4/30/2015.
Mossman, D., MD (2013) Psychiatric ‘holds’ for nonpsychiatric patients. Current Psychiatry 12 (3). Date accessed 4/30/2015.