You respond to a call at the request of the police
department to check out a “sick case.”
You arrive to find an 18-year old male without complaints. The police tell you that they need you to
check him out – he is acting weird.
During your exam, you find the patient to be calm and cooperative. He knows what day of the week it is, what
city he is in, and tells you his name.
There are no signs of alcohol consumption. He stopped taking his medication a few days
ago, but he can’t remember what it is that he was supposed to be taking. Medication names are hard to remember
sometimes. He stopped the medication by
choice, not due to running out or anything.
He prefers how he feels when he isn’t on it. He explains to you that there is no problem
and seems to be a nice guy, but his eyes are not meeting yours. When you ask him what he is looking at, he
explains that his cat is asking him to stay home. You do not see a cat.
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| Oh, there he is, the evil bastard... By Mrmiscellanious, via Wikimedia Commons (Public Domain) |
You, being a smart medic, know that this patient should
probably go to the hospital. When you
suggest that course of action to the patient, he declines.
You work to try to convince him to go to the hospital, but he won’t
agree to voluntary transport.
What do you do? He is
oriented to person, place, and time. He
is sober. Is he allowed to refuse?
This is an example of why I hate the term
“soberandcompetent.” That’s how I am
going to spell it from now on, because that is how it is said. Soberandcompetent. I hate the term because “sober” has grey
areas. “Competent” is a legal term that
is decided in court, and also has grey areas.
Awake, alert, and oriented times three (or four) is unhelpful. Decision making capacity is
what we are trying to assess – is the patient capable of making his or her own
decisions?
Let me walk through each of those sentences and see if I can
convince you too.
Sober is a term that is loaded with grey areas. Listen, most of us have been in various
stages of alcohol intoxication. I’ve
found myself completely sober, buzzed, too drunk to drive, falling down drunk, and woke up
in dried vomit and not known where I was drunk.
Which level do we care about? Can
buzzed people refuse? Drunk people? Certainly not falling down drunk, right?
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| Can someone "hold my hair drunk" refuse? By Landii [CC-BY-SA-2.0], via Wikimedia Commons |
The problem that I have is that there are grey areas in
assessing people for clinical signs of intoxication. Speech clarity is subjective, except at the
completely clear and completely unintelligible ends of the scale. The same goes for gait – is a little stumble
a sign of ataxia or a sign that the patient didn’t see the uneven
sidewalk? Supposedly objective findings
like blood alcohol levels don’t necessarily have anything to do with how well a
person walks and talks (or drives). Most
signs don’t work well in assessing drug intoxication. I mean, many people can suck down a whole
joint and not slur their speech. So the
term “sober” is pretty subjective. What
we actually care about is whether a patient has the capacity to make decisions for
themselves.
Here’s what Dr Steven Pantilat says about competence: “Physicians
[along with paramedics and other clinicians] commonly confuse competence and
decision-making capacity. Competence and incompetence are legal designations
determined by courts and judges. Decision-making capacity is clinically
determined by assessment.”1 Incompetence is a legal determination made in
a court of law. Quit using the term
competence, please. We don’t care about
competence; we care about whether a patient has the capacity to make decisions
for themselves.
Orientation (AAOx3) is only the beginning of determining
decision-making capacity. You’re right
that a person who can’t tell you who, where, and when they are is probably not
capable of decisions. But, once again,
grey areas. What if a person knows that
it is August and that their 10th wedding anniversary was last week,
but they don’t know what day of the week it is?
We don’t care about orientation to three questions; we care about
whether a patient has the capacity to make decisions for themselves.
How does one assess decision-making capacity? Capacity entails:
- The ability to make and communicate a medical choice
- They don’t have to be able to speak, but a patient has to be able to communicate a choice regarding their care. Uncooperative silence is not communication regarding a choice.
- The ability to appreciate diagnosis, prognosis, suggested care, alternatives, and risks/benefits of all the choices
- Can they repeat back to you, in their own words, what you said is going on? Did they "get" what you told them? They don’t need to be able to teach a med school class on the subject, but can they understand their options in layman’s terms?
- The ability to make decisions without delusions or coercion
- No hallucinating. No abusive husbands standing behind you smacking their palm with a fist…
- The ability to use logical reasoning2
- Can they link two ideas together in a simple way? For example: Heart attacks are dangerous, and if I am having a heart attack that would be bad. Is their plan a vaguely logical one, even if not something you would do?
In short, people need to be able to take medical information
that you give them, synthesize it into information that is meaningful to them,
and make a decision based on that.
Simply, does the patient understand and appreciate what is going on and
communicate their choice?
Soberandcompetent is not what you should be looking for. Decision making capacity is the threshold you should cross before a patient can refuse, or be involved in deciding about other aspects of their care.
In Part 2, I will explain some of the ways you can form an
opinion as to whether the patient has decision making capacity. Stay tuned…
1. Jones RC, Holden T. A guide to assessing decision-making
capacity. Cleveland Clin J Med
2004;71(12):971-975.
2. Pantilat S. Ethics Fast Fact: Decision-making Capacity. UCSF School of Medicine Fast Facts.
2008. http://missinglink.ucsf.edu/lm/ethics/content%20pages/fast_fact_competence.htm
Assessed August 22, 2014.
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