Thank you, Dr Nelson, for an unconventional case today that allowed us to pursue a discussion regarding patient capacity and the role of our foundational ethical principles during these difficult cases.
Specifically, Dr Nelson present a patient with schizophrenia who presented with acutely worsening shortness of breath secondary to massive malignant pleural effusion from known extensive stage SCLC. Having previously undergone 2 rounds of chemotherapy and suffering significant side effects, the patient decided to forgo further treatment and expressed her wish to discharge home with comfort measures.
The questions were raised:
- Does this patient have capacity to make this decision?
- How does her underlying schizophrenia affect her capacity?
- What do you do when the patient’s wishes don’t align with your own or those of the patient’s family members?
To help answer these questions and equip you with some tools for future similar encounters, here are some helpful resources:
• The medical ethics alphabet: autonomy, beneficence, confidentiality, do no harm/non-maleficence, equality. When in doubt, go back to basics and honor these principles. With these are your guide posts, you will be thoughtful in your approach to the patient and dilemma at hand. (picture below)
• Have confidence with capacity: This is not only something we can and should assess, it is something that the primary team is best suited to do. As the primary team, we know the patient best and thus in the best position to understand and advocated for what is truly right for the patient. This NEJM article discusses the topic nicely and offers this helpful review of how to approach capacity assessments. (picture below)
• Be conscious of unconscious bias: Below are some of the key points that Dr Nelson nicely discussed in her review of this topics:
o Impairment in capacity is not a hallmark of schizophrenia; in fact, the majority of patients with schizophrenia do have capacity (estimates range from 10-52%)
o Physicians are more likely to identify a patient as lacking capacity if the patient is making a choice other than what the physician sees as appropriate, regardless of the demonstration of the 4 domains of capacity
o We tend to overestimate the capacity of our non-psychiatric patients