Capacity

So as part of being on the psychiatry team on the consult service, I get called a lot to go assess if a patient has the capacity to make a medical decision.  That decision can be anything, e.g. leaving the hospital, agreeing to the procedure, going to the bathroom instead of having to have a catheter, etc.  Sometimes, it's very clear that the patient doesn't have capacity.  For example, there was a patient with brain tumor who was being evaluated for decision to seek subacute rehabilitation following discharge from the hospital, and when I went to go see him with my senior resident, he looked at us and told us that he believed he had no brain tumor, and that we had promised him earlier in the day that he could go home when in fact we had never met him.  Other times however, it's not so clear.  Another patient today had gross hematuria (bleeding from the urethra) and needed a cystoscopy (tiny camera through the urethra to look at the bladder) to evaluate the bleeding.  Her bleeding was so bad that her hemoglobin level was dropping to dangerous levels and she needed to be transfused multiple units of blood during her hospital stay.  Despite this, she wanted to go home because she felt no pain.  After evaluating her with my attending physician, he came to the conclusion that she had the capacity to agree to having the cystoscopy, but didn't have capacity to refuse it.  She understood that having the procedure was beneficial to her, but didn't understand that not having the procedure and going home was detrimental.  In a way, it sounds like we're forcing her to have the procedure, but apparently, it's not, and many doctors operate on this paradigm.

Assessing whether someone has the decision-making capacity for choices that impact the quality of their lives is a huge responsibility, and one that is not always easy.