A 22-year-old woman is brought to the emergency department by her husband for right-sided abdominal pain and vaginal bleeding. A urine pregnancy test is positive. Serial hCG levels and a transvaginal ultrasound confirm an ectopic pregnancy. The patient's vital signs are stable with a blood pressure of 106/68 mm Hg and pulse of 92/min. She is responsive, participates in her care, and reports that her pain is improving with oxycodone. When the patient is informed of the diagnosis, she begins to cry saying, "My husband and I have been trying to get pregnant for so long." The physician discusses treatment options, including medical versus surgical management, with her. The patient tearfully reports that she would like to have the surgery done "to get it over with as quickly as possible." Her medical history is unremarkable except for a psychiatric diagnosis of schizophrenia. On arrival a few hours ago, the patient said she had no psychiatric symptoms, including hallucinations. At that time, she also reported being adherent with her medications, aripiprazole and sertraline, which her husband confirms. Which of the following is the most appropriate course of action for obtaining informed consent for the patient's procedure?
Although this woman has a diagnosis of schizophrenia, it is well controlled and there is no indication that her decision-making ability is impaired due to psychosis or other factors. She is conscious, is able to participate in her own care, and can give consent for the procedure.
Capacity is a patient's ability to understand the illness, treatment options, and consequences and to express a choice reflecting a preference. It is used in medical situations to determine if someone has the ability to give informed consent to receive or refuse a specific intervention. Assessing capacity is especially important when someone's cognition may be impaired, such as in neurological conditions (eg, dementia) or severe psychiatric illness. However, the presence of a psychiatric diagnosis does not render a person incapable of making decisions.
(Choice A) A patient's consent should be "presumed," rather than obtained, in an emergency. This includes situations in which the patient is unconscious or incapacitated or when no surrogate decision maker is available. Had the patient been unconscious or unstable with rapid deterioration, the physician may have considered the situation to be an emergency and proceeded with presumed consent.
(Choice B) If there is evidence that the patient lacks capacity to make treatment decisions (eg, delirious, psychotic symptoms interfering with rational thought process), then a surrogate decision maker, usually the spouse or next of kin (commonly a parent or adult child) can be approached for consent.
(Choice D) It is also important to note the difference between competency and capacity. In contrast to medical capacity, which can be assessed by a physician, competency is a legal definition determined by the courts.
(Choice E) Although pain medications can alter mental status, there is no evidence that this patient is overly sedated or incapable of making decisions.
Educational objective:
Patients with psychiatric diagnoses can give informed consent as long as they have capacity, meaning that their judgment and decision-making abilities are determined to be intact at the time of treatment.