Capacity for Consent

[Encephalopathy]

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Say you had an MR Pt living at a state mental hospital on a conservatorship with a questionable diagnosis of SCZ. Pt has a h/o countless ingestions (pens, batteries, etc) followed by EGDs for removal.

My question: does approval for the EGD need to be obtained from the conservator each time? Especially if the pt is absolutely willing to undergo the procedure?

Does capacity even come into play if there is no conflict between what the pt and what the dr want?

 

[masterofmonkeys]

My only similar experience was on Medicine, where we had several patients that did not have capacity for consent. The social worker handled most of it, but I know that we had some degree of blanket consent for routine types of care (CT, EGD/Colonoscopy, PICC line, IV antibiotics, etc).

 

[michaelrack]

Say you had an MR Pt living at a state mental hospital on a conservatorship with a questionable diagnosis of SCZ. Pt has a h/o countless ingestions (pens, batteries, etc) followed by EGDs for removal.

My question: does approval for the EGD need to be obtained from the conservator each time? Especially if the pt is absolutely willing to undergo the procedure?

Does capacity even come into play if there is no conflict between what the pt and what the dr want?

I don't know the answer to your first question (whether you need to get consent each time, or whether a blanket consent would cover all EGD's).

As far as your second question, whether the patient is willing to undergo the procedure doesn't make a difference. You still have to get consent from the conservator.

 

[PsyDGrrrl]

I don't know the answer to your first question (whether you need to get consent each time, or whether a blanket consent would cover all EGD's).

As far as your second question, whether the patient is willing to undergo the procedure doesn't make a difference. You still have to get consent from the conservator.

A patient who is under conservatorship never has the legal ability to enter into a contract or consent to a procedure. The conservator has to be the one to consent. In the case of this type of surgery, the conservator would have to give the consent but it may be that they can give a blanket approval for repeated procedures of the same kind. I believe that is the way it works at the hospital I work in.

ETA: Even if they have given a blanket consent for procedures, they still have to be notified whenever there is a change in the patient's status, there has been an incident, and medical treatment is needed.

 

[whopper]

OT, but you might want to investigate why this person is ingesting items. There has been no strong & hard data on why some psychiatric patients do this type of behavior--yet some do. It could lead to a publishable case study.

 

[Encephalopathy]

Thanks for the replies, guys, it clears things up.

Whopper, pt has said in the past that ingesting provides relief from anxiety in a compulsive-type OCD way. Also, pt is extremely disruptive on the wards and tends to get a lot of Ativan and even morphine in attempts at pacification for the sake of the other patients/nurses/doctors. Kind of a messed up cycle as pt has been admitted 4 times in 4 weeks, but there's not much an intern can do about it.

 

[masterofmonkeys]

so the pt basically has an impulse control disorder like pyromania or cutting or kleptomania or something.

Is the pt on an SSRI and/or clomipramine?

Given the frequency with which this appears to be happening and the issue of danger to patient, it wouldn't be unreasonable to start the pt on both drugs...

I know there's some talk of using AEDs for it (makes sense sort of), but I don't know of any studies or specific drugs.

Just a not-so-humble MS4's thought.

 

[kugel]

Just my two cents:
Be careful with the info you've received so far about conservatorships. It's not wrong. It's just that different states have different types of conservatorships and guardianships. For instance, in CA there is a separate mental health conservatorship (called LPS Conservatorship) under which the Conservator provides consent for psychiatric treatment and often living arrangements, but CANNOT (in most cases) provide consent for non-psych medications or treatments. Probate Conservatorship is what's used when a person is demented and can no longer make any medical decisions, effectively becoming a "minor" in regards to medical decisions. However, both can have specific clauses allowing other specific actions from the conservator - so you need to know the limits of each conservatorship you encounter.

Other states have other laws.
You can ask your hospital Risk Mgt dept for an analysis of exactly what any particular conservatorship or guardianship means. Since this is a legal document, the legally oriented Risk Mgt dept is often the best source for exact info - whereas I've found other docs and Soc Workers often operate off of myth and rumor about the rules of different conservatorships.