Okay, but what if they don't understand all that?
Easy: they don't have capacity.
. Do I have the power to make the old lady who doesn't understand why her bed sores are dangerous go to a SNF when all she wants to do is go back home to her filthy apartment?
Unless something's different with the way your hospital handled it vs the places where I've done C&L, once you write down they don't have the capacity, your responsibility ends.
It's up to the primary doctor to decide. Often times several factors have to be put into place to decide the next step, and these are things that usually are outside your responsibility.
If they asked for a recommendation on whether or not the patient has capacity, you answered it, it's over.
Now if the primary doctor wanted you to answer other questions, like what to do if they don't have capacity, I can't give you an answer there but can tell you that this is likely really the primary doctor's responsbility, not yours, and unless the next decisions are within the scope of psychiatry, you could humbly wrote so in the chart and decline the request. (Better to call up the primary doctor and explain this diplomatically.)
I had a situation where a I had a consult where a patient was labelled as psychotic because she was emergency rushed to the hospital while having several pets at home and she was worried about their status because no one could feed them. None of the nurses would address her concerns (for days!) and eventually got fed up with her cries for help and labelled her psychotic and ordered a consult.
I figured out what was going on, after having to calm her down (she was very upset and crying), she did fine with concentration and memory, no history of mental illness, and after I told her I was trying to get to the bottom of what happened, it all came out. I wrote it in the chart, and the treatment team freaked out because it basically brought out the truth that they weren't listening to her concerns and for all we knew her pets were now dead from neglect, if not killing each other for food (I figure large dog and small dog, among several other pets, if starving may try to eat the other).
I got a call from the nurse who angrily demanded what they should do about it. I answered something to the effect of..., "I'm a psychiatrist, not a pet detective. This is not a psychiatric issue. Please call the social worker and the legal department. Have a nice day."
A few minutes later I got a call from the social worker, very worried, and demanding what they should do. I responded, "Did you ever go to a McDonalds and get lousy service, then go across the street to a pizza place and complain to the pizza people about the McDonalds?" She told me no. I responded, "Yeah well I'm the pizza place. It's not psychiatry. If you want to go to the administration and demonstrate how pets not being fed is psychiatry and can somehow be managed by me, knock yourself out."
At that time I was a resident. I had a feeling they were going to try to push me do handle this since they were counting on the "over-eager resident can be exploited because they don't know how the system really works" phenomenon. By that time, I knew what was going on, and I also figured that the more they complained about it, the more it would just expose what a huge problem they made, so I was willing to rattle that saber, especially since I was really just doing my job, and the nurses involved had a history of demanding psych consults for stupid reasons (Depression: patient is sad because the Eagles lost). It was their mess that they created. They should fix it.
