Capacity Question; Consult Psychiatry

[jbomba]

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I have recently started a hospital gig where I need to handle floor consults that arise on occasion. I haven't done consult psych in at least 4 years now (during residency). I get a lot of capacity eval requests and they are almost always - we want you to assess for medical decision making capacity. period.

My understanding was there had to be a specific question to assess capacity; a person could have capacity to refuse a medication but not have capacity for a medical procedure, for example. Therefore you can't broadly ask me or anyone to assess for global medical decision making capacity. Same would be true for DNR vs Full code, etc type decisions is my understanding. I often send these back and ask for more clarification before I assess the patient - am I being unnecessarily difficult?

In the event a patient is found to not have capacity for a medical decision that risks life or limb, how do we/primary team actually enforce this? What is the protocol once I determine they lack capacity?

Appreciate any advice to these ( very rudimentary) questions.

 

[Bartelby]

Correct, the team should tell you the situation and why they are questioning capacity. You should then insist that the team come with you to explain the risks and benefits of the decision to the patient right in front of you. This accomplishes two things:

1- You ensure the patient was educated accurately. You don't know all procedures' risks and benefits, so this is important.
2- Sometimes the team just needs to talk to the patient and this solves the whole issue.

That takes about five minutes.

As for enforcement check with your hospital and state laws. It is variable from institution to institution and place to place, so it's good to clarify before you are in the middle of a difficult situation.

 

[brosa]

As said, you are correct. Around 99% of the times, the primary team will be much better to assess capacity than a psychiatrist, since they will be more aware of whatever treatment/procedure is being planned.

 

[Celexa]

Agree with the above. There has to be a specific question. I'm usually pretty open and generous in taking consults--teams often fumble questions, but that also reflects why they need the consult--but on capacity, there has to be a specific medical decision at hand or I won't see the pt. And I firmly agree about going to see the pt with the primary team. Its the cheat code to these consults, bc the teams that genuinely need your help will almost always agree and be grateful for the help, and the ones that don't have their plans together and are trying to fob off hard decisions to someone else are forced to get their act together. With the primary team there, as the consult psychiatrist I can work to bridge the communication gaps.

 

[comp1]

I hate to be jaded about this because of course the posters above are giving you the academically correct answer and certainly how you should handle things at an academic institution. However, I think the reality really depends on how exactly this hospital is setup and how you are reimbursed. Can you actually get the primary team in the room with you at the same time? Are you going to have to drive back or are you all hanging around the hospital together all day? Are you being paid by the patient (ie looking for consults) or is this a salaried position? If the former, you want to make this as easy as possible and throw up as few barriers as possible to getting consults. If the latter, you want to educate the primary team (the actual patient as opposed to the identified patient) on how to do capacity evaluations themselves as opposed to repeatedly consulting you to do them. Ideally in that case you want informatics to build a template for them to fill out regarding capacity. CAN you actually do a global medical decision making capacity assessment? It's not black and white. Some patients don't know where they are or why are in the hospital or heck their name. Some are non-responsive. Yes, even though you don't personally know the specific risk of infection from an appendectomy, these patients do indeed lack capacity to understand the risks and benefits of any intervention. How much you want to push these specific cases is really dependent on your particular hospital's setup and culture. If you can, talk to other CL doctors who have or are working at your hospital to get a feeling for how things work best. I find that a lot of consult questions actually revolve around "enforcement." A lot of teams want you to somehow magically force a patient into surgery which is usually not going to happen. Regardless of capacity, sometimes it's about educating teams that if a patient isn't assenting, the risk is often much greater than the benefit to "forcing" them to do something and then end up breaking bones (the patient's or the teams).

 

[calvnandhobbs68]

ts the cheat code to these consults, bc the teams that genuinely need your help will almost always agree and be grateful for the help, and the ones that don't have their plans together and are trying to fob off hard decisions to someone else are forced to get their act together.

Ah reminds me of the good old days of "auto consult psychiatry for capacity because the nurse said the patient was acting kind of weird" from every surgery service.

 

[Merovinge]

Ah reminds me of the good old days of "auto consult psychiatry for capacity because the nurse said the patient was acting kind of weird" from every surgery service.

Particularly funny with NSGY because they are still brain doctors. It was like, pt odd, consult psych because we can't spend more than 2 minutes with a patient to keep up our 10k++ RVUs...

 

[FlowRate]

Regardless of capacity, sometimes it's about educating teams that if a patient isn't assenting, the risk is often much greater than the benefit to "forcing" them to do something and then end up breaking bones (the patient's or the teams).

Definitely an important consideration for the discussion with the team prior to seeing the patient. "If I determine they lack capacity and they refuse, do you feel so strongly about this that you're willing to go to court to get a judge to force them to have the procedure? Is it actually the case that they will (relatively) imminently lose life/limb if this procedure isn't done and there are absolutely no reasonable, if suboptimal, alternatives?"

 

[aquatic ape]

Get these all the time. Now have aps asking for capacity for guardianship for patients who just don’t take care of themselves. I feel like a lot of time the hospitalists are either so uneducated and unknowledgable that they don’t grasp the concept of capacity, or are playing dumb. A lot of times it is case management saying “do they have capacity “ and hospitalists don’t know what it means so then they ask me. The question I often ask is, are you going to restrain them and force them to do physical therapy? If not, then it doesn’t matter whether or not they can decide to refuse it. I do work with a lot of foreign trained physicians, so laws and practice might have been different where they trained and that’s why the knowledge gap

 

[MusicDOc124]

This is one of the biggest components of the "liaising" of CL.


Here's my epic smart phrase if you find this helpful at all. Wrote it out like this as it may also answer some of the questions for the primary team and detail some of what I would go over in the eval.

Feel free to steal. Also feel free to make suggestions!

"
Capacity Evaluation


The patient has been given adequate information regarding the nature and purpose of the recommend plan of care, as well as the risks, benefits, and alternatives including continuing without treatment***.


Understanding the relevant information and situation

1. Does the patient describe his/her health problem: {YES/NO:24896} ***
2. Does the patient describe the recommended treatment: {YES/NO:24896} ***
3. Does the patient list the possible benefits and risks (or discomforts) of the recommended treatment: {YES/NO:24896} ***
4. Does the patient state any alternative treatments and their risks and benefits: {YES/NO:24896} ***
5. Does the patient list the possible risks associated with forgoing the recommended treatment: {YES/NO:24896} ***

Appreciation of the situation and its consequences

1. Does the patient believe that they need some kind of treatment: {YES/NO:24896} ***
2. Does the patient understand what the treatment will likely do for them: {YES/NO:24896} ***
3. Does the patient give a reasonable answer regarding why the treatment team has recommended this treatment: {YES/NO:24896} ***
4. Does the patient give a reasonable answer regarding why they believe the treatment will have the above/stated effect(s): {YES/NO:24896} ***
5. Does the patient give a reasonable answer regarding what will happen if they are not treated: {YES/NO:24896} ***

Reasoning for decision about treatment options

1. Does the patient give me a reasonable answer regarding how they decided to {Accept/Reject:44730} the recommended treatment: {YES/NO:24896} ***
2. Does the patient give me a reasonable answer regarding why they chose (chosen option)*** over (alternative option)***: {YES/NO:24896} ***

Communicating a choice

1. Patient is able to communicate a choice/decision: {YES/NO:24896}
2. Patient has decided {For/Against:44731} the recommended treatment of *** for ***.
   

Capacity evaluations are for a single time and place and pertain only to the specific medical question discussed here. Capacity may be had for other medical concerns, and capacity differs from competency. Capacity may also change with time and situation.


Based on the above evaluation, and pertaining to the specific medical decision discussed here, patient is determined to {have/lack:44732} the capacity for medical-decision making at this point in time.


At this time, the patient does not need further evaluation and work-up from psychiatry***. Please re-consult if re-evaluation is needed.

"

 

[CopaceticOne]

Here's my epic smart phrase if you find this helpful at all. Wrote it out like this as it may also answer some of the questions for the primary team and detail some of what I would go over in the eval.

Feel free to steal. Also feel free to make suggestions!

The internist in me loved your capacity template. I've always greatly appreciated assistance from my psych colleagues for specific situations where a 3rd party eval is very helpful with challenging patients who give inconsistent decisions.

 

[FlowRate]

This is one of the biggest components of the "liaising" of CL.


Here's my epic smart phrase if you find this helpful at all. Wrote it out like this as it may also answer some of the questions for the primary team and detail some of what I would go over in the eval.

Feel free to steal. Also feel free to make suggestions!

"
Capacity Evaluation


The patient has been given adequate information regarding the nature and purpose of the recommend plan of care, as well as the risks, benefits, and alternatives including continuing without treatment***.


Understanding the relevant information and situation

1. Does the patient describe his/her health problem: {YES/NO:24896} ***
2. Does the patient describe the recommended treatment: {YES/NO:24896} ***
3. Does the patient list the possible benefits and risks (or discomforts) of the recommended treatment: {YES/NO:24896} ***
4. Does the patient state any alternative treatments and their risks and benefits: {YES/NO:24896} ***
5. Does the patient list the possible risks associated with forgoing the recommended treatment: {YES/NO:24896} ***

Appreciation of the situation and its consequences

1. Does the patient believe that they need some kind of treatment: {YES/NO:24896} ***
2. Does the patient understand what the treatment will likely do for them: {YES/NO:24896} ***
3. Does the patient give a reasonable answer regarding why the treatment team has recommended this treatment: {YES/NO:24896} ***
4. Does the patient give a reasonable answer regarding why they believe the treatment will have the above/stated effect(s): {YES/NO:24896} ***
5. Does the patient give a reasonable answer regarding what will happen if they are not treated: {YES/NO:24896} ***

Reasoning for decision about treatment options

1. Does the patient give me a reasonable answer regarding how they decided to {Accept/Reject:44730} the recommended treatment: {YES/NO:24896} ***
2. Does the patient give me a reasonable answer regarding why they chose (chosen option)*** over (alternative option)***: {YES/NO:24896} ***

Communicating a choice

1. Patient is able to communicate a choice/decision: {YES/NO:24896}
2. Patient has decided {For/Against:44731} the recommended treatment of *** for ***.

Capacity evaluations are for a single time and place and pertain only to the specific medical question discussed here. Capacity may be had for other medical concerns, and capacity differs from competency. Capacity may also change with time and situation.


Based on the above evaluation, and pertaining to the specific medical decision discussed here, patient is determined to {have/lack:44732} the capacity for medical-decision making at this point in time.


At this time, the patient does not need further evaluation and work-up from psychiatry***. Please re-consult if re-evaluation is needed.

"

Overall a very good template. Not that I do CL work on a regular basis any longer, but I've long felt pretty strongly that domain 4 (communicating a choice) requires one additional thing other than simple communication--consistency. Especially for the sort of higher-risk capacity questions we usually get consulted on. It doesn't really matter if the patient can communicate a clear choice if that choice changes frequently throughout the day.

 

[Ceke2002]

This is one of the biggest components of the "liaising" of CL.


Here's my epic smart phrase if you find this helpful at all. Wrote it out like this as it may also answer some of the questions for the primary team and detail some of what I would go over in the eval.

Feel free to steal. Also feel free to make suggestions!

"
Capacity Evaluation


The patient has been given adequate information regarding the nature and purpose of the recommend plan of care, as well as the risks, benefits, and alternatives including continuing without treatment***.


Understanding the relevant information and situation

1. Does the patient describe his/her health problem: {YES/NO:24896} ***
2. Does the patient describe the recommended treatment: {YES/NO:24896} ***
3. Does the patient list the possible benefits and risks (or discomforts) of the recommended treatment: {YES/NO:24896} ***
4. Does the patient state any alternative treatments and their risks and benefits: {YES/NO:24896} ***
5. Does the patient list the possible risks associated with forgoing the recommended treatment: {YES/NO:24896} ***

Appreciation of the situation and its consequences

1. Does the patient believe that they need some kind of treatment: {YES/NO:24896} ***
2. Does the patient understand what the treatment will likely do for them: {YES/NO:24896} ***
3. Does the patient give a reasonable answer regarding why the treatment team has recommended this treatment: {YES/NO:24896} ***
4. Does the patient give a reasonable answer regarding why they believe the treatment will have the above/stated effect(s): {YES/NO:24896} ***
5. Does the patient give a reasonable answer regarding what will happen if they are not treated: {YES/NO:24896} ***

Reasoning for decision about treatment options

1. Does the patient give me a reasonable answer regarding how they decided to {Accept/Reject:44730} the recommended treatment: {YES/NO:24896} ***
2. Does the patient give me a reasonable answer regarding why they chose (chosen option)*** over (alternative option)***: {YES/NO:24896} ***

Communicating a choice

1. Patient is able to communicate a choice/decision: {YES/NO:24896}
2. Patient has decided {For/Against:44731} the recommended treatment of *** for ***.

Capacity evaluations are for a single time and place and pertain only to the specific medical question discussed here. Capacity may be had for other medical concerns, and capacity differs from competency. Capacity may also change with time and situation.


Based on the above evaluation, and pertaining to the specific medical decision discussed here, patient is determined to {have/lack:44732} the capacity for medical-decision making at this point in time.


At this time, the patient does not need further evaluation and work-up from psychiatry***. Please re-consult if re-evaluation is needed.

"

Just from my own experience with my late mother needing a capacity consult in order to activate my medical guardianship, I'd also add something along the lines of, "Patient offered/given communication assistance as required/necessary". For example my Mum had significant hearing loss, so she relied on a combination of hearing aids and lip reading to communicate. Part of her capacity assessment included instructions from me to make sure she had her hearing aids in, and to face her and speak clearly.

 

[mistafab]

This is one of the biggest components of the "liaising" of CL.


Here's my epic smart phrase if you find this helpful at all. Wrote it out like this as it may also answer some of the questions for the primary team and detail some of what I would go over in the eval.

Feel free to steal. Also feel free to make suggestions!

"
Capacity Evaluation


The patient has been given adequate information regarding the nature and purpose of the recommend plan of care, as well as the risks, benefits, and alternatives including continuing without treatment***.


Understanding the relevant information and situation

1. Does the patient describe his/her health problem: {YES/NO:24896} ***
2. Does the patient describe the recommended treatment: {YES/NO:24896} ***
3. Does the patient list the possible benefits and risks (or discomforts) of the recommended treatment: {YES/NO:24896} ***
4. Does the patient state any alternative treatments and their risks and benefits: {YES/NO:24896} ***
5. Does the patient list the possible risks associated with forgoing the recommended treatment: {YES/NO:24896} ***

Appreciation of the situation and its consequences

1. Does the patient believe that they need some kind of treatment: {YES/NO:24896} ***
2. Does the patient understand what the treatment will likely do for them: {YES/NO:24896} ***
3. Does the patient give a reasonable answer regarding why the treatment team has recommended this treatment: {YES/NO:24896} ***
4. Does the patient give a reasonable answer regarding why they believe the treatment will have the above/stated effect(s): {YES/NO:24896} ***
5. Does the patient give a reasonable answer regarding what will happen if they are not treated: {YES/NO:24896} ***

Reasoning for decision about treatment options

1. Does the patient give me a reasonable answer regarding how they decided to {Accept/Reject:44730} the recommended treatment: {YES/NO:24896} ***
2. Does the patient give me a reasonable answer regarding why they chose (chosen option)*** over (alternative option)***: {YES/NO:24896} ***

Communicating a choice

1. Patient is able to communicate a choice/decision: {YES/NO:24896}
2. Patient has decided {For/Against:44731} the recommended treatment of *** for ***.

Capacity evaluations are for a single time and place and pertain only to the specific medical question discussed here. Capacity may be had for other medical concerns, and capacity differs from competency. Capacity may also change with time and situation.


Based on the above evaluation, and pertaining to the specific medical decision discussed here, patient is determined to {have/lack:44732} the capacity for medical-decision making at this point in time.


At this time, the patient does not need further evaluation and work-up from psychiatry***. Please re-consult if re-evaluation is needed.

"

I love your template. I use something similar but more pared down. I keep it simple with the Appelbaum criteria 1. communicate a consistent preference, Understand disease/situation using teach back method, 3. appreciate the consequences of treatment options, including no treatment, and 4. present a rationale that is appropriate given the patient's biopsychosocial context.

I also like the "single point in time" and "single decision" type line and use something similar. I tend to throw in a line that "any physician can assess capacity."

I also provide a DOI for the Appelbaum article. Not sure if anyone reads it but at least they are provided a reference if they want to try it on their own.

 

[MusicDOc124]

any physician can assess capacity.

I add this as needed so I don't forget to delete it when I'm actually giving a second opinion so it's not taken the wrong way!

 

[MusicDOc124]

Just from my own experience with my late mother needing a capacity consult in order to activate my medical guardianship, I'd also add something along the lines of, "Patient offered/given communication assistance as required/necessary". For example my Mum had significant hearing loss, so she relied on a combination of hearing aids and lip reading to communicate. Part of her capacity assessment included instructions from me to make sure she had her hearing aids in, and to face her and speak clearly.

I add this in some form in the subjective as the brief history and situation I take/discuss when necessary. This isn't my whole note, just the very specific capacity stuff that goes under my assessment and leaks into my plan!