Location
Philadelphia, PA
Start Date
1-5-2024 1:00 PM
End Date
1-5-2024 4:00 PM
Description
I. Introduction
An assessment of capacity is a critical part of the surgical consent process in order to ensure that the patient understands the risks, benefits, and alternatives to treatment. When a patient refuses life-saving care, it is essential to evaluate them to determine their capacity for decision-making. While there are specific components to a capacity evaluation, the capacity assessment process can be clouded by other factors in the patient’s history. The purpose of this case study is to illuminate the myriad challenges faced by surgeons assessing capacity in patients with complex social and psychiatric backgrounds.
II. Case
A 53-year-old African-American female presented to the hospital with wet gangrene of the left lower extremity. During the course of her hospitalization, she underwent multiple surgeries to address the life-threatening infection. Throughout the process, the patient refused life-saving intervention on a number of occasions despite remaining adamant that she wished to live. The psychiatry service was consulted to perform a capacity evaluation. Assessing her capacity to make medical decisions proved challenging due to undiagnosed psychiatric illness, paranoia, delirium, and various social determinants of health. She was found to lack capacity due to her failure to articulate the consequences of refusing treatment. The patient’s daughter was temporarily placed in charge of making decisions, and ultimately, the patient received a court-appointed guardian upon discharge from the hospital.
III. Discussion
A capacity evaluation is an important part of the consent process and assesses the patient’s ability to synthesize information regarding their illness and the treatment options to make a choice congruent with their values. This patient did not appreciate the complexity and severity of her diagnosis, denying the possibility of progression of infection, loss of limb, and/or death. In lieu of intervention, she preferred to pray and wait for religious healing. Further complicating the matter, she displayed characteristic traits of paranoid personality disorder. While a psychiatric diagnosis on its own does not preclude capacity, its influence on her decision-making contributed to a lack of capacity. Additionally, as a Black female of low socioeconomic status, she had deep distrust in the medical system due to the historical mistreatment of patients of a similar background. Her financial hardship, lack of formal education, and poor access to healthcare resources also certainly contributed to her difficulty with health literacy and distrust of the system. A multidisciplinary and team-based approach was used to navigate this issue. The decision-making process included the patient, her family, psychiatry, surgical team, and social services to facilitate communication between all parties involved. By involving the patient in these discussions, she was able to retain dignity and feel partially in control despite her lack of capacity. Therefore, it is important to always consider how a patient’s social history and social determinants of health may impact their experience navigating the healthcare system.
Embargo Period
6-17-2024
Included in
Challenges in capacity: A case report exploring social determinants of health and psychiatric illness
Philadelphia, PA
I. Introduction
An assessment of capacity is a critical part of the surgical consent process in order to ensure that the patient understands the risks, benefits, and alternatives to treatment. When a patient refuses life-saving care, it is essential to evaluate them to determine their capacity for decision-making. While there are specific components to a capacity evaluation, the capacity assessment process can be clouded by other factors in the patient’s history. The purpose of this case study is to illuminate the myriad challenges faced by surgeons assessing capacity in patients with complex social and psychiatric backgrounds.
II. Case
A 53-year-old African-American female presented to the hospital with wet gangrene of the left lower extremity. During the course of her hospitalization, she underwent multiple surgeries to address the life-threatening infection. Throughout the process, the patient refused life-saving intervention on a number of occasions despite remaining adamant that she wished to live. The psychiatry service was consulted to perform a capacity evaluation. Assessing her capacity to make medical decisions proved challenging due to undiagnosed psychiatric illness, paranoia, delirium, and various social determinants of health. She was found to lack capacity due to her failure to articulate the consequences of refusing treatment. The patient’s daughter was temporarily placed in charge of making decisions, and ultimately, the patient received a court-appointed guardian upon discharge from the hospital.
III. Discussion
A capacity evaluation is an important part of the consent process and assesses the patient’s ability to synthesize information regarding their illness and the treatment options to make a choice congruent with their values. This patient did not appreciate the complexity and severity of her diagnosis, denying the possibility of progression of infection, loss of limb, and/or death. In lieu of intervention, she preferred to pray and wait for religious healing. Further complicating the matter, she displayed characteristic traits of paranoid personality disorder. While a psychiatric diagnosis on its own does not preclude capacity, its influence on her decision-making contributed to a lack of capacity. Additionally, as a Black female of low socioeconomic status, she had deep distrust in the medical system due to the historical mistreatment of patients of a similar background. Her financial hardship, lack of formal education, and poor access to healthcare resources also certainly contributed to her difficulty with health literacy and distrust of the system. A multidisciplinary and team-based approach was used to navigate this issue. The decision-making process included the patient, her family, psychiatry, surgical team, and social services to facilitate communication between all parties involved. By involving the patient in these discussions, she was able to retain dignity and feel partially in control despite her lack of capacity. Therefore, it is important to always consider how a patient’s social history and social determinants of health may impact their experience navigating the healthcare system.