Capacity consult, chronic delusions, refusing pacemaker

[SmallBird]

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I see this sort of stuff often. Even if the patient was fully conserved with someone else legally making all decisions for them, how exactly are you going to do SURGERY over their objection. There is consent and there is assent. You really do NEED something resembling assent unless the patient is unconscious and it's emergent. How else? You're going to tie the patient down and forcibly anesthetize them while they are screaming and thrashing to not do it? The risk/benefit for this given the potential harm to the patient while forcing such treatment is just not there. This is to say nothing about post-surgical requirements/needs. Feel free to talk to all the lawyers and ethicists you need, but ultimately it comes down to practicality.

They would sedate the patient. Happens every day.

 

[WisNeuro]

Fair enough, I think I'm still reacting to your statement about transfer of liability in the event of an adverse outcome. But sure, document well, I agree 🙂

Nothing fear mongering about that statement, anytime you involve yourself in care, you take on liability. Anytime that care involves legal matters like capacity/competency, that becomes a more salient issue. It's more about awareness of that simple fact and taking steps to minimize it as much as possible.

 

[nexus73]

it is in

 

[Stagg737]

Actually, I don't believe any state has a medical hold for lack of decision-making capacity in general (i.e. not due to mental illness, intoxication, etc.). It is an enormous, but universal, oversight and really we aren't allowed to hold such patients unless they meet the common law standard. The common law standard (at least in my state) is incapacitated + precipitously dangerous, with the index case being a woman in the midst of jumping out of a window to escape imagined pursuers. Many ICU patients could meet this standard, but even if they don't the still usually get held because it would be unethical to do otherwise.

Fair, I guess I was more referring to the colloquial term of a “medical hold”. Though I would say the definition of “precipitously dangerous” will vary a lot and may not even be necessary in some states. Where I’m at it explicitly states in legislation that if someone is lacking capacity then decisions go to a surrogate, which is not uncommon to be a physician if family is not reachable or they just don’t have anyone.

 

[aim-agm]

Fair, I guess I was more referring to the colloquial term of a “medical hold”. Though I would say the definition of “precipitously dangerous” will vary a lot and may not even be necessary in some states. Where I’m at it explicitly states in legislation that if someone is lacking capacity then decisions go to a surrogate, which is not uncommon to be a physician if family is not reachable or they just don’t have anyone.

Caveat: This can vary by state and I am not familiar with other states, but I believe these principles are broadly true.

An incapacitated patient cannot consent to treatment, but they can either assent, object, or be non-objecting. If they are assenting or non-objecting, then a surrogate's consent is generally adequate. If they are objecting, then much more stringent requirements come into play and can require a court order for treatment over objection, in some cases even if the patient is incompetent and their guardian consents.

 

[Batman's Underwear]

I see this sort of stuff often. Even if the patient was fully conserved with someone else legally making all decisions for them, how exactly are you going to do SURGERY over their objection. There is consent and there is assent. You really do NEED something resembling assent unless the patient is unconscious and it's emergent. How else? You're going to tie the patient down and forcibly anesthetize them while they are screaming and thrashing to not do it? The risk/benefit for this given the potential harm to the patient while forcing such treatment is just not there. This is to say nothing about post-surgical requirements/needs. Feel free to talk to all the lawyers and ethicists you need, but ultimately it comes down to practicality.

Indeed. Some providers believe that lacking a capacity for a procedure equates any means possible to get the procedure done. There was a capacity evaluation case which the patient refused biopsy of incidental discovery of small abdominal mass, some distance away from a major blood vessels. Surgery team was gung-ho about the getting this mass, and stated that this was a life-threatening condition that required immediate life-saving measures. Our team found the patient to have capacity to refuse the procedure because we did not believe surgical team's assessment.

Surgery team got angry, documented their own capacity evaluation, deemed her "incompetent" for all medical procedures. For several weeks, patient barricaded herself in her room, only allowed meal service to entered the room. She would often throw items to surgery attending and intern, when they try to sedate her for the procedure. Hospital security, rightfully, did not help surgical team to hold the patient. This was elevated to ethic/CMO/Risk management, not sure what happened and the patient was eventually discharged.

When patient refuses treatment, primary team thinks that psychiatry team has a magic wand to solve everything including liability. In some cases, capacity evaluation can cause more problems and more headaches, especially risk assessment of undergoing treatment versus its alternative is not accurately performed by the primary team.

 

[WisNeuro]

Indeed. Some providers believe that lacking a capacity for a procedure equates any means possible to get the procedure done. There was a capacity evaluation case which the patient refused biopsy of incidental discovery of small abdominal mass, some distance away from a major blood vessels. Surgery team was gung-ho about the getting this mass, and stated that this was a life-threatening condition that required immediate life-saving measures. Our team found the patient to have capacity to refuse the procedure because we did not believe surgical team's assessment.

Surgery team got angry, documented their own capacity evaluation, deemed her "incompetent" for all medical procedures. For several weeks, patient barricaded herself in her room, only allowed meal service to entered the room. She would often throw items to surgery attending and intern, when they try to sedate her for the procedure. Hospital security, rightfully, did not help surgical team to hold the patient. This was elevated to ethic/CMO/Risk management, not sure what happened and the patient was eventually discharged.

When patient refuses treatment, primary team thinks that psychiatry team has a magic wand to solve everything including liability. In some cases, capacity evaluation can cause more problems and more headaches, especially risk assessment of undergoing treatment versus its alternative is not accurately performed by the primary team.

The fact that they documented "incompetence" for all medical procedures/decisions is a pretty clear indication that they had no idea what they were doing. Hopefully hospital legal asked them to stop documenting such good evidence for opposing counsel.

 

[aim-agm]

The fact that they documented "incompetence" for all medical procedures/decisions is a pretty clear indication that they had no idea what they were doing. Hopefully hospital legal asked them to stop documenting such good evidence for opposing counsel.

"Stop demonstrating incompetence by calling this patient incompetent."

 

[whopper]

Your job in this situation has limits. You do a capacity evaluation. That's it.

Over and done even if your consultation doesn't leave the surgery team in good place. That's not to say this isn't a very serious and complicated case that it should be brought up in this forum for teaching purposes.

But all you're supposed to do is all you're supposed to do. If you leaves surgery in a bad place that's not on you so long as you did your job.