How does a clinician decide when to listen to the decisions of their patients or override those decisions for their patients’ safety? This is a question of decision-making capacity, which is impacted by several factors and is sometimes hard to determine.
Lecturer in the Department of Psychiatry at Yale University and lead writer Rocksheng Zhong, MD, MHS, Assistant Professor in the Department of Medical Ethics and Health Policy Dominic Sisti, PhD, and PMC Co-Director Jason Karlawish, MD, co-authored an article discussing the pragmatic approach to assessing decision-making capacity.
During his residency at the University of Pennsylvania, Zhong observed many cases involving ethics and decision making with Karlawish, his mentor.
Assessing a patient’s decision-making capacity helps clinicians figure out if they should respect their patient’s wishes. For example, a person with capacity may refuse treatment even if it is life-saving, whereas a person without capacity may be overruled by their clinician. The question that this article wants clinicians to consider when capacity is unclear is: “Is the treatment, when involuntarily administered, medically appropriate and available?”
“The most important takeaway from the article is that when assessing capacity, it is often useful to think ahead to what will happen as a consequence of the capacity finding,” Zhong said.
The authors argue that the status of a patient’s capacity matters mostly when the benefits of the treatment outweigh the risks of using force to administer the treatment. Involuntary treatment may include involuntary medications, physical restraints, detention in the hospital and constant observation, and may not be steps the treatment team are willing to take. For example, forced treatment for a patient who refused a multivitamin would be viewed as unnecessary. On the other hand, if they refused intravenous antibiotics, forced treatment may be considered beneficial if the patient’s infection is severe.
The authors recommend that capacity evaluators work closely with treatment providers to understand when the balance of the risks and benefits of forced treatment shifts. They write, “when the risks clearly outweighs the benefits, then the intervention is medically inappropriate.”