A 58-year-old man with a history of chronic renal insufficiency and schizophrenia comes to the emergency department with chest pain. A 12-lead ECG shows ST elevations in leads II, III, and aVF. The patient's troponin and CK-MB levels are elevated. A cardiology consult is called and the patient is prepared for emergency percutaneous coronary intervention. The risks and benefits of the procedure, including the risk of contrast-induced renal failure, are explained to the patient. He shows an understanding of his condition, the benefits of percutaneous coronary intervention, and the risks of not performing the procedure. However, despite continued persuasion, he refuses any procedure that might lead to renal failure. On mental status examination, the patient is alert and oriented to person, place, and time. His mood is anxious and his affect is flat. He says that he prefers to live alone, "because you can't trust people not to steal your things." The patient hears voices calling his name daily. He has no suicidal ideation. Which of the following is the most appropriate next step in management of this patient?
Assessment of decision-making capacity | |
Criterion | Patient task |
Communicates a choice | Patient able to clearly indicate preferred treatment option |
Understands information provided | Patient understands condition & treatment options |
Appreciates consequences | Patient acknowledges having condition & likely consequences of treatment options, including no treatment |
Rationale given for decision | Patient able to weigh risks & benefits & offer reasons for decision |
Patients who demonstrate decision-making capacity have the right to refuse interventions, including lifesaving treatments. Although this patient has a diagnosis of schizophrenia, he is alert and oriented; able to communicate a choice; and demonstrates understanding of his condition, the proposed treatment, and ability to reason through the risks and benefits of treatment or lack of it. His flat affect, general suspiciousness, and hearing nonthreatening voices on mental status examination are consistent with mild severity of schizophrenic illness and are not impairing his ability to weigh this specific decision.
Having a psychiatric diagnosis, in and of itself, should not be a determining factor in capacity assessments. Patients with a history of psychiatric illness should be carefully assessed to determine if acute symptoms are directly impairing their ability to reason (eg, a patient who has severe delusions related to the medical condition, disorganization, or cognitive impairment may lack capacity and require a surrogate decision maker).
(Choices A and C) There is no evidence that this patient's psychotic illness is interfering with his ability to make a decision. In addition, administering an antipsychotic is unlikely to have any immediate effect on mental status apart from possible sedation.
(Choice B) The right to refuse treatment includes emergency procedures.
(Choice E) A second opinion would be indicated if there was uncertainty about the treatment of choice.
(Choice F) A surrogate decision maker is needed only when the patient lacks capacity.
Educational objective:
Patients with psychotic illness do not necessarily lack decision-making capacity. If a patient's psychotic symptoms do not interfere with understanding or ability to communicate a choice regarding medical treatment, the patient has the right to refuse treatment, even if it would be lifesaving.