Lack of capacity to refuse medication?

[Scorcher31]

Obviously this may vary it a bit from state to state, but I was still curious for perspective on this. Generally if a patient lacks capacity to make a specific decision, we can get a surrogate decision maker (usually a family member) to help make the decision.

If by applying the capacity evaluation we feel a patient does not have capacity to appropriately choose which medications they take and which they refuse, can psychiatric medications be administered against the patients wishes with permission of a surrogate decision maker in a non emergency (IE standing not PRN)?

I am under the impression this would still be involuntary administration of psychiatric medications which has a separate (possibly legal) procedure, and we cannot simply do what the family wants despite patient temporarily not having capacity.

What if the patient is refusing a non psychiatric medication like Lisinopril instead and the family requests it be given (still no capacity). Is there any difference?

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[michaelrack]

the patient still has to assent even if they do not have capacity to consent to treatment. if someone is refusing lisinopril how are you going to give it to them without assaulting them? same for psychiatric medications. if geriatrics we sometimes give patients medications without their knowledge or tell them its for something else but it's irrelevant whether the patient has capacity or not if they are actively refusing/resisting in a non-emergent setting. personally i don't believe in compelling drugs against people's will except in cases of emergency but that's another debate.

depending on the setting and meds, they can sometimes be mixed with food etc.

In psychotic conditions you can give monthly depot injections- perhaps have a caregiver bribe the patient with food to assent

edit: agree with whopper below, the above are meant to be things one can do after a legal proceeding

 

[michaelrack]

Obviously this may vary it a bit from state to state, but I was still curious for perspective on this. Generally if a patient lacks capacity to make a specific decision, we can get a surrogate decision maker (usually a family member) to help make the decision.


What if the patient is refusing a non psychiatric medication like Lisinopril instead and the family requests it be given (still no capacity). Is there any difference?

In most states an informal surrogate is not sufficient in non-emergent psych cases, you need to have a judicial hearing and have a conservator/guardian appointed to force psych meds (non-emergency)

 

[whopper]

Some states require that when it comes to meds, the patient cannot be forced meds unless there's a court hearing where the judge determines if it's in the patient's best interests. In such cases the following questions must be answered by the treating doctor
1) What disorder(s) does the patient have that require treatment?
2) Did the doctor provide an adequate amount of information about why they need the treatment(s) the doctor wants forced?
3) Are there alternative treatments that were considered and offered that are appropriate/lesser invasive?

If you can't answer 1--don't expect it to pass
2-if you didn't provide, don't expect it to pass
3-if yes, don't expect it to pass
That is assuming the judge actually knows what he/she is doing and has studied case law. I've seen some judges not know WTF this is. It's a difficult position to know the laws but not to be able to be the one who interprets them and be working with a judge who has the final say and he doesn't know the case law.

Other states have a differing system where the question is asked-"Would the patient have wanted the treatment before they lost the capacity?" E.g. a patient with a TBI who now does not have capacity. Would he have wanted the treatment?

One cannot put medications in a patient's food without the patient's knowledge unless the court or guardian approved it.

Finally there's what's been nicknamed a sliding scale capacity. In several instances, doctors offer treatments to patients where capacity was not fully assessed because in doing so, a doctor could spend several minutes. To do a capacity assessment on every single patient would be needlessly wasteful and not cost-effective.

With all of the legal cases brought up concerning capacity, the fear of giving a medication without assessing everyone was brought up. In some instances it's not really possible to assess the patient especially in a critical point where they may only have moments to live. Doctors did not want to wait until they were sued for the law to give an answer on what to do.

The AMA gave the guidelines that in cases where a patient accepts a treatment, even if their capacity is questionable, but the treatment follows professional guidelines of being an appropriate medication (e.g. FDA approved, backed by peer-reviewed journals, etc) for the patient's condition, the level of scrutiny a doctor must give to see if the patient has capacity should be considered weak. If the patient refuses treatment, and they are in need of the treatment, then the doctor's scrutiny over capacity should be very strong.

In short, if the patient wants the treatment and you want to give it to them, and it's an appropriate treatment, you shouldn't worry about it.

In the absence of legal standards established by laws or cases, following professional society guidelines like the AMA could be used as an adequate defense in most cases should you ever be sued.

 

[zolof]

Agree with Whopper. Depending on the state laws once a patient has been found to not have capacity, the legal guardian takes or DPower of At takes over. Usually in the order of Spouse, Adult children, siblings, other family, friends, healthcare providers. But remember that capacity is decision specific and time specific, and doesn't encompass every issue that the patient faces, he/she may be able to choose a power of attorney, but may not be able to make a complicated decision about the best kind of treatment to have.