The medical/surgical team’s involvement in the assessment of medical decision-making capacity

KEYWORDS:

• Medical/surgical teams
• decision making capacity assessments

Decisional incapacity is a common and often unrecognized problem in medicine. Medical/surgical teams (also referred to as primary teams) should be aware of the scope and impact of decisional incapacity on hospital days and healthcare costs. This awareness partially comes from participating in and conducting decision-making capacity evaluations. Medical/surgical teams are well situated to assess decision-making capacity themselves in uncomplicated cases; they can consult psychiatry for assistance for uncertain or more complicated cases.

Typically, primary teams request assistance from psychiatry to assess a patient’s decision-making capacity. The medical/surgical team contacts the psychiatrist for various reasons: a patient wants a high-risk/low-benefit procedure, a patient refuses a high-benefit/low-risk procedure, or a patient has a mental illness even though there may not be active symptoms interfering with the patient’s decision-making capacity (as examples). Earlier articles by Appelbaum and Grisso provided the foundation for conducting such assessments; recent articles (such as Moye et al.) have built upon this foundation and integrated legal, clinical, and ethical dimensions in decision-making capacity [1–3]. The MacArthur Competence Assessment Tool–Treatment (MacCAT-T) is a reliable and validated instrument to assess capacity to make treatment decisions; the American Bar Association and American Psychological Association have published a combined handbook to prepare and orient psychologists to these assessments in older adults [3,4].

After the primary team relays the hospital course and the patient’s decision, the psychiatrist will interview the patient to inquire about treatment choice; encourage him/her to paraphrase disclosed information regarding his/her medical treatment; ask the patient to describe his/her view of his/her medical condition, proposed treatment, and likely outcomes; and ask the patient to compare treatment options and consequences as well as offer reasons for selection of option [1,2]. The psychiatrist will also review the chart and potentially interview nursing staff, other medical staff, and family members to gather collateral information prior to rendering an opinion on the existence of a mental illness and the effect of the mental illness (or medical illness in the case of a delirium) on the patient’s decision-making capacity. The psychiatrist then places the hard copy of the consultation in the patient’s chart (or enters the consultation in the electronic medical record) to complete the process.

I opine that the primary team’s involvement in the actual capacity assessment can be extremely beneficial. Participation of the primary team could enhance the communication of medical information, allow the psychiatrist to study team dynamics, and permit the primary team to do more assessments in the future by themselves. Before the primary team becomes involved, the psychiatrist needs to ask the primary team to participate in this assessment; should the psychiatrist not ask, the primary team could ask in a collegial manner to participate in the assessment. If the psychiatrist concurs with this request, then issues such as the best time to conduct the assessment, how urgent it is, etc. can be worked out. Since the primary team is proposing a certain treatment, it is in a better position medically and legally to discuss the benefits/risks of treatment and other aspects of informed consent with the patient than the psychiatrist. The primary team directly hears the patient’s responses and observes the patient’s behaviors. By having the primary team participate in the assessment, the psychiatrist can observe the dynamics between team members and the patient to see if interpersonal conflicts are contributing to the patient’s decision and then offer suggestions to improve those dynamics and reduce potential conflicts for current and future patients. From the patient’s perspective, the presence of the primary team during the assessment can lessen the stigma that a psychiatrist is involved in his/her care, especially if the patient does not have a history of mental illness. The psychiatrist can debunk myths and avoid pitfalls as these assessments are being conducted.

At times, capacity is questioned when the actual problem is disclosure (e.g. the primary team did not disclose the information in a manner that the patient could understand and/or did not address the patient’s anxiety during disclosure). Participation of the primary team could illuminate disclosure issues that are impacting decision-making capacity. This is an important point in view of research that shows a wide variability (between 21% and 86%) of patients are able to recall potential risks and complications of their medical procedure; in addition, general healthy normal controls (not acutely ill) may recall only half of the information disclosed about health conditions and treatments [5,6].

Some facilities have only one psychiatrist performing consultation duties. Due to the potential for a backlog in consultations, it may take longer for a psychiatrist to conduct these assessments than the primary team. By participating in this process, the primary team can learn how these assessments are conducted, can be better informed on when to request them in the future, and can potentially conduct an assessment without psychiatric assistance for uncomplicated cases. Should a patient lack decision-making capacity, the primary team and psychiatrist can work together to determine the best course of action.

There are potential disadvantages to having the primary team participate in these assessments. The primary team may not derive educational or practical benefits from this endeavor. Dual agency/conflict of interest can be a concern. The primary team is responsible for providing treatment; participating in the assessment could potentially ‘muddy the waters’ as to where the treatment role ends and the consultative role begins. There are also practical concerns such as minimizing disruption in patient care (i.e. ensuring participation in the assessment does not interfere with other patients’ care) and time constraints (i.e. availability of the primary team). If there are multiple questions needing answers (e.g. decision-making capacity and treatment of underlying mental illness), having the primary team present could potentially interfere with the relationship between the psychiatrist and the patient and impair the psychiatrist’s ability to make treatment recommendations.

In summary, medical/surgical teams should be involved in these assessments. Although there may be drawbacks, I believe that the involvement of the primary team could allow the primary team to conduct more assessments by themselves (thus acquiring a valuable clinical skill in their repertoire). In my opinion, they should attempt to assess decision-making capacity themselves; primary teams can consult psychiatry for assistance if they are unsure whether or not the patient has decision-making capacity after an initial assessment or for more complicated cases. Despite the disadvantages, participation in and conduction of these assessments could potentially decrease the risk of a communication breakdown, increase interdisciplinary cohesion, and enhance the delivery of care.

Declaration of interest

The author has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.