Assessing Preferences for Patients who Lack Decision Making Capacity (Andereck & Fulbright 1/15/25)

 A recording of this presentation is available HERE.

Deep gratitude to Dr. William Andereck and Robert Fulbright for a thought-provoking presentation this week on Decision-making Capacity. This is an issue that we encounter with surprising frequency on the inpatient medicine service, and the distress that decision-making capacity causes on patients and providers is intense. 

This is definitely a presentation that is better watched than summarized, but I did take a few notes. 

The concept of Patient Consent first arose in 1914, Benjamin Cardoza, "Every human being with a sound mind has a right to determine what he does with his own body."

This concept, of course, was brought to light in the context of the Tuskegee Study (which ran 1932-1972) and the subsequent Belmont Report (published in 1979). It was the Belmont Report (which I don't think I have ever heard of before this lecture) in which Informed Consent became a thing. 

The Belmont Report outlined 3 principles:

1. Beneficence
2. Justice
3. Respect for persons (which was ultimately morphed into Respect for the autonomy of the person)

Non-maleficence (do no harm) was not included.

Of note, Dr. Andereck stressed, autonomy at the time was not meant to be interpreted as "the right to demand whatever you want". Rather, it was meant as a freedom from interference, the right to say "no". Somewhere along the last 50 years, it has become interpreted as a "positive right". From Dr. Andereck's perspective, early bioethicists were clear that if a medical intervention does not benefit the people, there is no obligation. 

Competence is defined as 1) having values and goals 2) the ability to communicate those and 3) reasons to do or not do something related to this goals. Competence is NOT the same as Capacity. 

Capacity is specific>> the question should always be capacity for what?

Capacity it temporal>> it can wax and wane

Capacity is the perspective of a 3rd party>> patients never tell us that they are incapacitated. It must be observed from an outside party.

Applied to medicine, then, capacity becomes

1. the ability to 

Psychiatric Emergencies in the Hospital (Kostick, 2/3/2021)

Many thanks to Dr. Talia Kostick for an excellent presentation on Psychiatric Emergencies in the Hospital: etiologies, clinical presentations, and treatments. She also included a bit on medical-decision making capacity and involuntary hospitalization-- issues we confront quite frequently in the hospital.

Dr. Kostick took us through 4 cases of patients we cared for at SSRRH with these Psychiatric Emergencies. If you want to see the recording, it is available here: https://youtu.be/Tr0I22vNuiY

Psychiatric emergency: when a psychiatric condition causes an imminent threat to the life of the patient or the possibility of permanent neurologic or physiologic damage. These include:  

• Serotonin Syndrome
• Catatonia
• NMS 
• Anticholinergic Toxicity
• Suicidal Intent (not covered her)

Serotonin syndrome: potentially fatal drug induced condition, caused by too much serotonin in the synapses in the brain. Patients present with a combination of neuromuscular, autonomic, and mental status symptoms

• s/sx: clonus, tremor, sweating, tachycardia, restlessness, confusion, delirium
• meds common cause: MAOi, Antidepressants (SSRI, SNRI, TCAs), opiates, natural health products. Worse in combination, high dose
• treatment: 
• discontinue any/all serotonergic drugs
• supportive care (esmolol, nitroprusside)
• sedation with benzos
• paralytics and intubation for hyperthermia
• in serious cases serotonin antagonists

Catatonia: displaying 3 or more of 12 psychomotor features (see table)

• usually diagnosed inpatient
• majority in depression, can occur up to 35% of patients with schizophrenia
• s/sx: immobility, mutism, withdrawal and refusal to eat, rigidity, echolalia (see table)
• treatment: benzos! (1-2mg of SL, IV or IM lorazepam--> repeat in 3 hours), also ECT effective
• more likely to respond if bipolar, less likely if schizophrenia

Neuroleptic Malignant Syndrome (NMS): alteration in the autonomic and somatic nervous system caused by decreases in function of the central dopamine system

• 10% mortality (more fatal than serotonin syndrome)
• incidence 0.01-0.2% of all patients treated with antipsychotics
• greatest risk in high dose first generation psychotics (e.g. haldol)
• diagnosis of exclusion: 1) exposed to dopamine antagonist 2) mental status change 3) "lead pipe muscle rigidity", autonomic instability (tachy, tachypnea, hypertension), hyperthermia w/diaphoresis, elevated CK
• tx: stop dopamine antagonist, can add dopamine agonist ( bromocriptine, amantadine, levodopa), decreased noradrenergic activity (with benzos)

Anticholinergic Toxicity: 

• blind as a bat, hot as a desert, mad as a hatter, dry as a bone, red as a beet (see image)
• LOTS of meds with anticholinergic effects: antiemetics, corticosteroids, analgesic, steroids
• Tx: stop the med, provide supportive care, in severe cases (cardiac effects), can administer physostigmine

Capacity Assessment: 4 parts

1) Comprehension: Can patient express an understanding of current medical conditions, risks/benefits of proposed treatments?

2) Expression of a choice: Does the patient have the ability to state and explain their decision?

3) Appreciation: Is the patient able to appreciate the consequences of their decision?

4) Depression/delusions/intoxication: if any of these affecting decisions, do not have capacity