Question

Discuss some of the risks involved with denying a patient capacity. Specifically, is it fair to limit the capacity of someone with a mental illness such as depression or anxiety? Explain your thinking.

Answer 1

Ans) Physicians do not have unlimited discretion to refuse to accept a person as a new patient. Because much of medicine is involved with federal regulations, physicians cannot refuse to accept a person for ethnic, racial, or religious reasons. Some physicians refuse to treat attorneys.

- The complexities involved in capacity assessment have stimulated efforts to develop standardized measures and quantifiable scales to measure capacity.

- These efforts are ambitious and worthwhile; however, the clinical utility and adaptability to various clinical situations have yet to be clarified.

- Referral to such instruments can offer guidelines for the clinician assessing capacity to make treatment decisions. Regardless of the instrument used or the interview approach undertaken, any reasonable assessment of capacity will need to address the patient's ability to comprehend the prevailing medical condition and the available treatment options, as well as the risks and benefits.

- Appreciation for the seriousness of the medical condition and the ability to weigh risks and benefits are essential components to the capacity assessment, but are subjective and cannot easily be subjected to standardized instruments.

- Thus, the primary care physician is thrust into the conflict of rendering care for the patient while looking after the patient's interests and wishes. If the patient is deemed to lack capacity, the interests of the patient must be respected as conveyed in advance directives or living wills. Surrogate decisions are necessary if no directives are available. Nonetheless, the wishes and interests of the patient must be adhered to as much as is possible or known. Resorting to the judiciary may be required if no proxy or surrogate is available for decision making.

- Primary care physicians can reduce some of the potential uncertainties by introducing the benefits of advance directives and designation of a health care proxy in discussions with their patients. In this way, the patient's autonomy and self-determination can be ensured should he or she become incapacitated and unable to make reasoned decisions.

- Invoking the assistance of psychiatric consultants goes beyond mere reassurance that the physician's actions are medically and legally sound.

- The psychiatrist can assist with the capacity assessment, diagnose and treat underlying psychiatric conditions that may pose an impediment to decision making, and facilitate patient-physician and (if necessary) surrogate-physician communication.