1.3 Decisional Capacity
Louis C. Charland, PhD, and Mark Lachmann, MD, MHSc, CCFP
- To clarify the role of decisional capacity in informed consent
- To discuss problems associated with decisional capacity and addiction
Mr. N., aged 46 years, is admitted to emergency by ambulance after collapsing on the street at 4:30 in the afternoon. He arrives intoxicated (from alcohol and illegally purchased prescription opiate pain killers, in this case, Percocet). As he is wheeled into the emergency triage room, he is clutching his heart. In addition to being intoxicated, he also appears to be in considerable pain. After routine examination, questioning and laboratory testing, the patient is diagnosed with an acute myocardial infarction and severe substance dependence to opiate drugs.
Apparently, Mr. N. became addicted to prescription opiates as a result of a workplace back injury, from which he has never fully recovered, leaving him to sustain himself on social assistance. No longer able to obtain opiates by prescription, Mr. N. feeds his addiction to opiates through purchases from street dealers. He claims to have been using opiates for the last two years.
Although Mr. N. is clearly intoxicated during interview, slurring his words and rambling in speech, he is judged sufficiently decisionally capable — that is, "mentally competent" — to provide consent to treatment by the attending physician. Consent is verbally sought and obtained regarding treatment for his myocardial infarction. Intravenous treatment is initiated, and a non-opioid sedative is administered. After being informed upon questioning that proper treatment will require several days of hospitalization, the patient is transferred to a ward and quickly falls asleep.
Six hours later, Mr. N. suddenly awakes, reporting nausea, generalized malaise and muscle aching. These discomforts soon evolve and there is a marked increase in his symptoms of distress. The physician on call is called to the bedside. After reading Mr. N.'s chart, the resident on duty records "opiate withdrawal." Non-opioid sedatives are administered, but the symptoms of distress persist. Several hours have elapsed, and by this point the patient is in acute distress. The patient starts pleading with hospital staff, asking for prescription opiates — "anything you have."
One of the team physicians suggests that it would be best to provide this man with opiate drugs — to avoid his withdrawal symptoms and to avoid having his condition worsen his myocardial infarction. Methadone treatment is suggested by another staff person on the treatment team. Discussion by the team centres on the fact that the patient is already addicted to "prescription drugs." The team decides to prescribe regularly dosed oral morphine to treat his withdrawal and dependence as treatment of his cardiac condition is pursued. Methadone is not offered.
The oral morphine dosing stabilizes the patient, although he continues to want more narcotic. He is no longer in withdrawal. He agrees to the treatment plan of his heart attack. He states that he is able to stay in the hospital for cardiac care and admits that the morphine is helping him, acknowledging he wants further narcotic. He states quite openly that he is addicted to Percocet and does not wish to stop using now. He understands that he has had a heart attack and that he is medically unstable and at high risk of having further cardiac complications. Another night passes. He then leaves the ward in the early hours of his third day just at nursing shift change, having disconnected himself from the cardiac monitor and removing his intravenous catheter. He swears at the staff on the way out, and is noted to be fully clothed and purposeful in his exit. He waited until after his morning dose of morphine before leaving. On morning rounds, the cardiology team simply finds an empty bed and an angry nursing staff.
Back on the ward floor, the treatment team assembles and reviews the incident. A review of the patient's treatment progress indicates that he may not survive very long upon leaving hospital so shortly after his myocardial infarction. If he does survive, he will likely have far worse cardiac function than would have been possible if he had received a full course of treatment. One member suggests that the patient should have been rehospitalized involuntarily, since he was clearly unstable mentally and in a condition to harm himself. Worries are expressed that the patient could eventually sue them on these grounds. The hospital lawyer is consulted the next day and advises that there is little chance that such a suit would be successful, since the team followed the "standard of care." The patient is deemed to have been sufficiently competent to refuse treatment.
- Was consent appropriately obtained?
- Are these good grounds for refusing to offer methadone treatment for withdrawal symptoms — while the patient is required to be hospitalized?
- Was the patient decisionally capable to give informed consent and refuse treatment?
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