Category: Education

Shadowfax presents a case study in applied ethics and asks:

What would you do if you were the doctor in this situation (or the administrator/ethicist/judge called to offer guidance)? Would you provide supportive care and allow him to die, or would you violate his express wishes and intubate him?

Physicians often call psychiatrists for consultation in similar, though less acute, clinical situations. These requests are called “assessments of decisional capacity”. Psychiatrists do not have a special license to make these assessments. Any physician can make a determination of decisional capacity. Many doctors ask psychiatrists to perform these assessments, however, as (1) psychiatric conditions can affect a patient’s decisional capacity and (2) psychiatrists have more experience than other physicians in assessing decisional capacity.

“Decisional capacity” refers to a person’s ability to make a decision for a specific clinical issue. This issue is usually related to treatment. After assessment, physicians can opine whether someone possesses or lacks decisional capacity for something specific:

• “He has the decisional capacity to refuse treatment for his prostate cancer.”
• “She does not have the decisional capacity to refuse surgery for her infected leg.”

“Competency”, which is often conflated with “capacity”, is a legal term. Only judges in courts of law have the power to deem someone “incompetent” and thus unable to make decisions for themselves.

Appelbaum and Grisso published an important paper that provides a four-point rubric to assess decisional capacity. (At only four pages, it is a short, high-yield article.) Most psychiatrists apply this rubric when assessing decisional capacity in medical settings. If the patient cannot fulfill any one of the four criteria, the patient probably lacks decisional capacity. As an exercise, let’s apply these criteria to the case that Shadowfax presents.

The question: Does the patient have the decisional capacity to refuse intubation and mechanical ventilation for treatment of his lung injuries?

1. Can the patient communicate a choice? This choice must be clear and remain stable over time. If the patient cannot (or will not) communicate a choice, the interviewer cannot assume that the patient has the ability to make a decision. (Consider one extreme: Someone who is in a coma.) If the patient repeatedly changes his choice, this has practical implications: A medical team and patient agree to launch Plan A. Right when Plan A is about to unfold, the patient refuses it. The team cancels Plan A, but then the patient says he wants Plan A. This is a problem.

The case patient appears to be communicating a consistent choice (refusing intubation).

2. Does the patient have an understanding of relevant information? Does the patient understand what the diagnosis means? the risks and benefits of proposed treatment? the risks of benefits of alternative treatments (which includes doing nothing)? Again, consider an extreme: If a patient does not understand that surgery involves the cutting of skin, that patient cannot make informed decisions related to surgery.

The case patient was able to comment that “refusing intubation would lead to his death.” He was apparently “unable to, or chose not to, articulate any reason that he did not want to be intubated”. From the available information, we do not know if this patient understood that he had a lung injury. (Was his choice based solely on the unpleasant thought of someone shoving a tube down his throat?) We also do not know if he understood the risks and benefits of intubation and mechanical ventilation.

3. Does the patient have an appreciation for the current circumstances and consequences? This may sound similar to #2, but there is a notable difference: This question asks if the patient understands the condition and treatment options as it applies to him. Patients with dementia, for example, might know the course and outcome of dementia after witnessing the condition in a relative, but may not recognize that their own cognitive function is impaired. Similarly, consider a procedure that results in death 50% of the time. If a patient says, “I’m not like everyone else! There’s absolutely no chance I will die!”, he lacks the ability to make informed decisions for himself for this specific issue.

It appears that the case patient recognized that if he refused intubation, he would die. We do not know if he understood that he himself had a lung injury and how available treatment might help (or hurt) him. (As an aside, one could argue that the patient has already demonstrated ambivalence about death and dying. Most people who have made the commitment to die generally will not go to an emergency room “on three consecutive days for suicidal ideation and non-life-threatening suicidal gestures”.)

4. Can the patient manipulate information in a rational manner? This asks if someone can apply sufficient logic to his current situation. Another extreme: If someone has the unshakable conviction that all surgeons implant microscopic, parasitic aliens into patients during operations, that patient lacks the ability to make informed decisions related to surgery.

From the available information, it is unclear if the case patient could manipulate information in a rational manner for this specific situation. We do not know the reasons why he did not want to be intubated. One reason could have been his stated desire to die. We do not know if he believed that he would have access to endless opiates in the afterlife. We do not know if he felt overwhelming guilt for damaging a tree and thus believed that he deserved to die. It may be unfair to assume that he cannot manipulate information in a rational manner simply because he could not state reasons for refusing intubation. However, it is also unfair to assume that he can manipulate information in a rational manner in the absence of data.

You may now recognize the amount of time and information needed to render an opinion about decisional capacity. (Furthermore, I personally believe that anyone rendering these opinions should consult with colleagues for quality control. Our personal biases affect our judgments. These extra discussions consume more time.) As a result, this process often cannot occur in acute medical situations.

Given the limited information (due primarily to the acuity of the situation), it is not clear if the patient had the decisional capacity to refuse intubation and mechanical ventilation for treatment of his lung injuries. One might lean more towards the opinion that he lacked decisional capacity, since he did not provide a convincing argument that he understood the relevant information or appreciated the situation and the consequences.

In addition to the rubric described above, some authors argue for a “sliding scale” in decisional capacity. If the patient in Shadowfax’s case was intubated, the physicians likely applied this “sliding scale”. I will describe it in further detail in a later post. For a preview, look over the comments in Shadowfax’s post.

During psychiatry training, residents are assigned “psychotherapy supervisors”. The resident sees a psychotherapy patient and then meets with his supervisor to review the session. Sometimes this means the resident will dump onto paper everything he can remember about the session: “She said A, that made me think about B, so I said C, and then she replied with D”. Sometimes, with the patient’s permission, the resident records the session on audio- or videotape. Together, supervisor and resident later review this data. The supervisor provides feedback and suggestions to teach the resident about psychotherapy and how to proceed with treatment.

During my last year of residency, one of my supervisors was a psychoanalyst. Every week, I went to her private office for supervision. A plush psychotherapy couch was near the window. She sat in the chair behind the head of the couch. I sat in the chair across from her.

About four months prior to my graduation, my patient—a man who had been single for several years—started dating a woman who worked in health care. I thought this was a positive development: Maybe he had learned that others did not share the opinion he had of himself. Maybe he learned to view himself with more compassion. Maybe he had developed more confidence when interacting with women.

When I shared this information with my supervisor, she looked at me with disbelief. She insisted that this was his reaction to termination.

“It’s a flight into health,” she said. “He’s found this woman now because you’re leaving.”

What is a “flight into health”? Malan says:

[It is] a concept which at first sight may seem to contain an inherent paradox. The paradox can be resolved by making it clear that the flight is into apparent health—the patient believes he has recovered but the clinician believes that unsolved underlying conflicts will give rise to more or less serious difficulty in the future…. [A flight into health may be] a way of avoiding either further painful conflicts or anxiety-laden feelings about [the] therapist. (p. 219)

“She works in health care, you work in health care. You are an important person in his life; he wants this new person to be an important person in his life. Don’t you think it’s interesting that he found this relationship right when you are about to leave?”

It was my turn to look at her with disbelief.

“How do you know this is all about me? How can you be so sure?”

My supervisor and I often revisited this topic in the remainder of our meetings. In fact, she wondered if my opposition to her suggestion was significant in our termination, the end of our educational relationship. (And, as psychiatrists are trained to do, we talked about it. Neither one of us changed our opinions.)

Though I disagreed with her assertion about my patient, I was more vexed with her unshakable confidence in her hypothesis. How could she know that she was absolutely correct?

Malan summarizes my sentiments about this issue:

… the therapist sees all the problems that his brief therapy has not resolved, and—in ignorance of systematic follow-up evidence—has no faith in the patient’s ability to mature further. (p. 218, emphasis mine)

Frick also argues that the concept of “flight into health” is cynical.

Neither my supervisor nor I pursued follow-up with this man. Only time would tell if his relationship signified recovery or avoidance.

To be clear, “flights into health” can happen. Some people find it much easier to believe that their conditions have improved, rather than acknowledge and endure “the pain and anxiety of further exploration and self-disclosure” (Frick).

Whether related to termination or not, what we say or think about someone often reveals more about us than about the person in question.