CME-MOC

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Time Stamps

• 3:02 Defining voluntarism
• 5:40 Four elements that influence voluntarism
• 10:26 How do you incorporate voluntarism into the capacity assessment?
• 16:11 Discussions with uncooperative patients
• 19:17 Protecting unrepresented patients
• 21:35 Clinician perspective
• 25:08 Moral distress

Show Notes

• Introduction
• Informed consent: For a patient to give informed consent, they need to have:
  1. Adequate information
  2. Decisional capacity to make the given decision
  3. Voluntarism
• Voluntarism
  • Definition: A concept described by Dr. Laura Roberts that describes our ability to make authentic, uncoerced decisions that are in line with our values and identity. 
  • Voluntarism can be influenced by 4 components:
    1. Developmental factors
    2. Illness-related considerations
    3. Psychological issues and cultural and religious values
    4. External features and pressures
  • Questions to consider: How do we incorporate voluntarism into our capacity assessments?
• There are a number of challenges that can arise during and after a capacity evaluation. The two discussed in this episode:
  1. Uncooperative patients
  2. Unrepresented patients
     • Hierarchy of medical decision making
     • Ethics committee involvement 
• Clinicians may find that capacity evaluations bring up a number of challenging emotions. The four discussed in this episode: 
  1. When patients make “bad” choices
  2. Physician Bias
  3. Treatment over objection
  4. Moral Distress
• Conclusion

Transcript

Margot: I want to revisit a case we talked about almost a year ago, in our episode on discharges against medical advice. This was a young man with a history of IV drug use, who came in with high fevers and was found to be bacteremic. When I walked into his room, I tried to explain our concern that he had endocarditis – a life-threatening infection of the heart valves – but he told me that he had to go home. His mother was having some legal trouble, he said, but he had huge pupils, and just kept yawning. I suspected that he was withdrawing from heroin, and that the desire to use again was driving his plan to leave, but he turned down my offer of methadone. He showed me that he understood the risks of leaving, appreciated that he could die if untreated, and had a perfectly logical reasoning. So he signed himself out AMA, and left.

A lot of questions can linger after a tough capacity evaluation. What about patients who show they have capacity, but seem to be pressured into a choice? What happens if the patient fails the capacity evaluation? Can we let this patient decide what happens with their body, or do we take that right away? I won’t pretend we hold all the answers, but we wanted a space to explore them. I’m Margot.

Jafar: I’m Jafar

Tamar: And I’m Tamar. Today, in part 2 of our capacity episode, we’re joined by Dr. Cindy Geppert.

Geppert: I’m a consultation, uh, liaison psychiatrist in Albuquerque, New Mexico. And I have been doing capacity evaluations for over 20 years. I probably at this point done thousands. I’m also a palliative care physician, do addiction medicine, and pain medicine as well. In my other life, I’m an ethics consultant at the National Center for Ethics in Healthcare  at the VA. So, from all those perspective all those perspectives, I became, uh, very interested in capacity as a psychiatrist, as an ethicist, and have made sort of that my specialty over the years.

Jafar: And just a quick disclaimer: If you hear some extra sounds in the background, it’s just some of Dr. Geppert’s excitement for decision making capacity coming through, thumping on the desk for added emphasis.

Geppert: I’m well known for running around rooms when I lecture, grabbing people and you know, doing all kinds of strange things.

Tamar: In this episode, we’ll first speak to Dr. Geppert about  the concept of voluntarism, an important but maybe unfamiliar consideration in so many of our patient interactions, including the one Margot just described. We’re then going to explore Dr. Geppert’s approaches to some other difficult scenarios that come up during and around the capacity evaluation.

Voluntarism

Brief Recap 

Jafar: Before we dive in, let’s run through a quick recap of our last episode on capacity. To have decision making capacity, a patient needs to:  1) communicate a choice, 2) understand the information we’re providing, 3) appreciate the impact that medical decision will have in their life, and 4) have the ability to reason through the risks and benefits of their different treatment options. Keep in mind that capacity is time and decision-specific–someone with delirium could be confused right now, but better after a few hours of fluids and antibiotics, and patients with dementia might not be able to weigh the risks and benefits of a surgery, but they can decide what they want for lunch. Remember that we’re not judging the content of a patient’s decision, but the path they take to get there.  

In most day to day discussions of medical ethics, this is where the bus stops, but we wanted to take you just a little further today. Decisional capacity is actually only one part of informed consent.

Definitions

Geppert: If you think of informed consent, there are three components. One is that you get adequate information that you can understand. The second is that you have capacity.  And the third, which we don’t pay much attention to is that you don’t undue internal or external coercion. Put positively, that’s that you have volunteerism, or voluntariness as some people like to say. So, Dr. Roberts who’s the chair of psychiatry at Stanford defines it as, what enables you to choose freely in the absence of coercion, and enables you to make decisions that you can enact your values of what you think is right as good in light of the situation, your history. It means you can be deliberate, purposeful, um, genuine and that your decision coheres with prior life decisions. So those are all a lot of, um, great high sounding words that, seemed very far away from what we often do, um, with the patients that we’re taking care of unfortunately. 

Jafar: Wow–ok so at first glance like a beautiful ideal what decision making could be, but we hope to show how this concept is not so impractical or esoteric.  

Voluntarism gets at how we make free, authentic decisions that are in line with our values.  But as people in the real world, we’re prey to many influences that constrain those decisions.  For example, I may want to stay in the hospital and finish these IV antibiotics for my health, but if I miss work for another week, I’m not going to be able to pay rent.   In this situation, you could say I have diminished voluntarism due to an external pressure.  Sure, I have understanding, appreciation, reasoning, and choice – but intuitively, there’s something else going on here that affects my decision making.  That’s what voluntarism gets at.   Tamar will help us break it down further.  

4 elements

Tamar: As Jafar just teed up, normally, to make a decision, we think about two things: someone needs the necessary information and needs to demonstrate capacity for decision making. But this third part, the concept of capacity for voluntarism, is something we don’t usually talk about. 

So let’s dig into what makes up voluntarism. In our conversation, Dr. Geppert described the work of psychiatrist Dr. Laura Roberts in defining four domains that influence voluntarism. We’ll touch on her work here and we encourage you to head to the references in our show notes for more. 

1. Developmental factors

Tamar: The first of the four elements impacting voluntarism are developmental factors. Roberts defines these as “cognitive abilities, emotional maturity, and moral character” that solidify as we become adults. Most adolescents and young adults just haven’t had enough experience or faced enough decisions to fully form their identity. It’s not always the case, but often a person’s age can be a surrogate for her knowledge about her own opinions and preferences. The decisions I made about my healthcare as a teenager are very different than those I make now. 

2. Illness-related considerations

Tamar: The second element that influences voluntarism is illness-related considerations. Both Dr. Roberts and Dr. Geppert mentioned a number of physical and psychiatric illnesses that can impair voluntarism, even when a patient can still demonstrate decisional capacity. For example, a patient’s judgment can be impacted by ambivalence or indecisiveness from depression, or the physical and psychological strains of severe uncontrolled pain or a substance use disorder. 

But illness-related considerations don’t always impair voluntarism — experiencing significant illness can actually also enhance it. Being faced with difficult and important decisions can really sharpen a person’s understanding of her own values. For example, a young woman undergoing cancer treatment may need to make premature decisions about fertility preservation or end-of-life preferences. She may need to determine and understand her priorities more than peers her age. 

3. Psychological issues and cultural and religious values

Tamar: The third influence on voluntarism that Roberts described is made of psychological, cultural, and religious values. These factors all impact how we make our choices and how we communicate them. 

You know, how do religious beliefs shape what we define as good and bad? How does belonging to a community shape what choices are acceptable to us? How do family structures impact who weighs in on our choices? And how do our cultures impact how these choices are communicated? Dr. Geppert discussed an example:

Geppert: I had a young Hindu woman who was involuntarily admitted and placed in a gown and put in the middle of a ward where everybody could see her, which ruined her marriageable ability, which was totally disrespectful. She went hysterical. Of course she got haldol and restraint and all of it was cultural. Just to have a bunch of strange men, while wearing a gown, looking at her. She was cognitively intact, should have probably never been admitted. Um, that’s, that’s a person who can’t, whose voluntarism is so diminished, they can’t make a free choice.

4. External features and pressures

Tamar: And finally, voluntarism is strongly influenced by external features and pressures. There are so many factors outside our control that heavily impact our choices.

Geppert: I think of those as all those huge socioeconomic things that are impinging upon all of us. Well, we can’t discharge them cause there’s nowhere to go or, he can’t pay for his diabetes medicines, so he keeps getting admitted for DKA. And so, these are all what I call, volitional and affective dimensions of how you make decisions. And if you look at decision making theory, nobody’s really rational. Everybody makes decisions emotionally and then reasons later. And no one’s really free.

Tamar: To Dr. Geppert’s point, some of these external pressures are familiar to us all: job commitments, financial constraints, responsibilities to family members. But there are also so many others that can much more significantly limit someone’s choices, or their ability to make decisions in accordance with their true, authentic values — like being in a psychiatric institution, in a nursing home; being incarcerated or homeless; being in an abusive relationship. 

Geppert: So it’s an illusion to think that we don’t, we’re not all coerced all the time. We’re all coerced, that’s the human condition. But when does it become so impinging that you can’t act on any of your values? That’s the way that I think of voluntarism.

How do we incorporate voluntarism into our capacity assessments? 

Margot: So now that we’ve defined voluntarism, we’ve come to our next big question: is this going to change my practice? At the top of the episode, Dr. Geppert mentioned that an informed consent discussion is based on having information, decisional capacity, and voluntarism. But she acknowledges that voluntarism doesn’t tend to be a formal part of our assessments:

Geppert: So courts don’t like to look at volunteerism because it’s fuzzy and messy and it’s hard to quantify. It’s even hard to qualify. And so it doesn’t make for good court cases that make you feel like you can make a clean decision. It’s not really included if you do a standard neuropsychological battery. So, most psychiatrists wouldn’t, I mean they would mention it as part of sort of a psychodynamic formulation or a psych assessment, but they’re really going to, you know, they’re going to stick to those four components.

Margot: It’s concepts like voluntarism that make medicine as much an art as it is a science. While we don’t tend to talk about voluntarism the same way we talk about the 4 tenets of decisional capacity, it lends a depth to the informed consent process that might otherwise get missed. For example, like we talked about in our episode on AMA discharges, if a patient’s decision-making process doesn’t really make sense, there’s usually a back-story that can help explain:

Geppert: I mean, how many times have you, like, I can’t figure out why this guy, you know, isn’t participating in his treatment or why he keeps coming back and it’s your medical student or your social worker or somebody finds out, ohhhh… he has five dogs. And so, you know, he has to take care of them. And so he can’t live anywhere. So he doesn’t have any place to put his, you know, um, medicines and they get stolen or whatever. So it’s all those sorts of things, but they can really impact your ability to make decisions and decisions that are authentic to your values.

Margot: We told Dr. Geppert about the patient I mentioned at the beginning of the episode, the patient who I suspected was withdrawing from heroin and wanted to leave AMA. As she explains, an informed consent discussion that only focused on decisional capacity would be incomplete: it would miss the impact that his withdrawal is having on his voluntarism:

Geppert: I think this guy could pull it together enough to answer our stupid psychiatry questions and be let go. Does that mean he’s making a free choice? I don’t think so. I think he sees no other option because the immediate distress, I mean heroin doesn’t … withdrawal doesn’t kill you, but you wish it would. And so he needs relief before he can try to work through this.  

Margot: If we understand the strains on someone’s voluntarism, we can try to take steps to alleviate those strains. 

Geppert: The first thing you should do when he says AMA is say, what can I give you? You know, do you need some opiate? Do you need a benzo? What do you need to calm down to feel comfortable and safe with me trying to work up your, your endocarditis?

Margot: Some of these problems are solvable, like the situation Dr. Geppert just explained. But there are a lot of situations I’ve come up against that feel so much bigger than me, like imprisonment, immigration status, and racism. Tamar mentioned that external features and pressures can make it really difficult for our patients to make decisions that are in line with their values: What do we do when our patient’s voluntarism is impaired by forces beyond our control? 

Geppert: Try to always get, try to get to the values even if I can’t actualize them. You know, I think from activist standpoint, you can do all, you can, you know, as, as a professional to change the laws. But the laws are always there and there are always going to be cases that, um, enrage you or make you indignant because you aren’t allowed to treat the patient because you’re not the one in power. And that’s not the structure. But I  try to always at least to be honest, mention it that I think so-and-so, if they had other options, um, would not choose this. There are certainly volunteerism considerations there that, that probably really seriously impair capacity. But no one’s going to really grasp it that way, right? Because it’s such a huge political issue and they don’t want to deal with it and they can’t deal with it.

Margot: We want to acknowledge how frustrating it can be when there are these problems we can’t solve. I feel like medicine trains us to have the solutions to our patient’s problems – but I can’t save my undocumented patient from wage theft, I can’t solve my patient’s housing problems, and there’s only so much I can do to help my patients with addiction. But it’s still worth thinking about them – it deepens our empathy for our patients. This can also be a call to action. Call your representatives, vote, protest, donate to causes you believe in if you can. We may not have the power to solve all these problems, but we can advocate for our patients.

To wrap up this section, a few key take-aways. Informed consent is based on information, decisional capacity, and voluntarism. Voluntarism gets at our ability to make authentic, uncoerced decisions that are in line with our values and identity. Voluntarism isn’t something we’re always formally assessing, but it’s a helpful lens to use if your patient is making a lot of conflicting choices, or if they’re coming to a decision that doesn’t seem like it’s in line with their values.

Uncooperative Patients 

What do you do if a patient doesn’t cooperate with the capacity evaluation?

Jafar: Ok, we want to step away from voluntarism and take the time with the rest of this episode to talk about other difficult elements of the capacity assessment. We’ll start with how to approach patients who won’t cooperate with the capacity exam, and also what happens when patients fail the capacity exam.  Specifically, we’ll talk about how to support unrepresented patients, and the difficulties of treatment over objection. Finally, we’ll turn the lens on ourselves, talking about physician bias and moral distress.

So first off, what do you do when the patient won’t cooperate with the capacity exam?  You’re trying to figure out what they understand about a situation… but they won’t answer any of your questions!  

First, we can say it’s fair to be suspicious when this happens, and we can take it as a red flag: when a patient doesn’t understand what’s going on, dodging questions or refusing to talk can be a protective strategy that keeps them from getting embarrassed or frustrated. But you need to draw the line somewhere. When a situation is medically dangerous enough that a person can hurt themselves by leaving the hospital or making some other choice, you may have to turn the conversation into an ultimatum:  

Geppert: I want to give you the best chance, right? To show you have capacity and go on your way and do what you want, but I really need to know. And so you gotta you gotta answer some questions. So that’s sort of a soft, in ethics terms, a soft, paternalistic approach, right? You know, you got to tell me before you can go, so just fine isn’t enough. How are you going to be fine? What are you going to do? What do you know about yourself and your situation different than I know as a doctor that makes you think you’re gonna make it out that door?

Jafar: If that doesn’t work, don’t try and keep pressing the issue head on–it will only further antagonize the patient and alienate yourself from them. Instead, Dr. Geppert suggests just trying to engage in casual conversation, which may subtly tell you what you need to know.

Geppert: If you have a lot of experience and skill and time you can usually come to a pretty good assessment of capacity just by talking. So often I just sit down in the bed and go, what do you do for a living? You know, what’s your cat’s name? The residents think I’m crazy cause I don’t, you know, ask any psychiatric questions, you know, if they’re watching Gunsmoke, I say, oh yeah, it’s Gunsmoke wasn’t that a great show? And you know, just whatever I can do as un-psychiatrically as possible. For example, patients that can make jokes and use wordplay probably have some capacity left. Those are higher order abilities. If they have a lot of verbal fluency, you know, there’s somebody still home. And so it doesn’t mean they’re going to make the best decisions, good decisions, rational decisions. But if you sit there and listen long enough, you’ll get a sense of how they problem solve. Can they think through things? Do they remember what they just said? Did they remember what you just said?

Jafar: Once you get the ball rolling in a conversation with the patient, having a little background information about them in your back pocket can be a helpful way to get to some of the harder questions about capacity–like what the patient can remember, appreciate, and reason through.

Geppert: Um, the other thing I’ll do is I’ll read the chart really carefully and I’ll have in the back of my mind, Hey, you know, you say you’re fine, but what happened the last time when you left and you ended up in that ditch? Um, tell me, tell me why you ended up in the ditch. Socratically kindly, sort of pushing them, trying to get clues about their reasoning ability. What are you going to do if you, if you leave now, how are you gonna avoid the ditch? Right. And whether they see that it’s really serious to end up there. 

Jafar: Ultimately, if a patient is not willing to speak with you, and you believe there is significant medical risk in leaving, we can’t assume they have decision making capacity.  We brought this up in our first episode on capacity, but it has to be said again: no discussion means no capacity, at least at that moment.  

Unrepresented patients

 Jafar: Another particularly difficult situation is a patient who doesn’t have capacity, but also has no one to speak on their  behalf–the so called “unrepresented patient.”  This might be a John Doe who comes in after a major trauma under an assumed name, an elderly nursing home resident without any family, or a patient with tenuous immigration status and no other identifiable contacts.  How do we make decisions for patients in this situation?  

As a reminder, the gold standard for guidance in medical decision making for patients who cannot speak for themselves comes from any prior documents that they may have written when they were lucid.  Advance Directives and Living Wills speak legally and directly in the patient’s voice. If these aren’t available, we look for someone they’ve chosen as their healthcare proxy, maybe their next of kin or other close contacts that could supply “substituted judgment”–what the patient would say if they could speak for themselves. If, and only if, both of these are truly absent do we move on to the lowest ring, which we call “best interests judgments.” 

Best interests judgments are the toughest spot to be in, because they depend entirely on what we value.  For instance, most people surveyed would not support the use of life-prolonging therapies if they were ever in a persistent vegetative state–but how can you make that call without ever knowing the patient?  Unrepresented patients without capacity are one of the most vulnerable groups in medicine, and it takes a tremendous effort to protect them from our individual values and biases:

Geppert: You really need a committee or leadership or somebody else who’s not directly involved in the care of the patient. It doesn’t have all those coercions right back to volunteerism who can try to help make a decision for this person. And you want to have oversight and checks and balances, um, to try to somehow figure out, um, what should we do here in this situation? Um, given that we really, really can’t find anybody but you have to come up with a policy, a protocol, a process, something for how you’re going to make decisions for this patient. You can’t, no, yes, no, yes in something as critical as trach or die. Um, and I think you always there on the side of life if you’re not sure.

Jafar: Long story short: don’t go it alone! These are exactly the times you need your local ethics committee to help work through this with you, while also integrating hospital policies and state laws into the process.

Clinician perspective

Tamar: In the final part of this episode, we wanted to grapple with a few difficulties that can come up around capacity assessments and the decision making process — not so much in determining whether a patient demonstrates decisional capacity, but the uneasy feelings these situations sometimes raise. 

Complexity #1: [Fundamentally conflicting priorities?] “Bad” for their health

Tamar: The first example we’ll discuss is the discomfort clinicians can feel when patients make decisions that are “bad” for their health. Dr. Geppert gave an example of a patient placing importance on his independence above all else:

Geppert: Like I had a guy who said, you know, I live in the East mountains, which is would be to you guys, the wild West frontier. And you know, I have a well and a septic tank and I don’t, I don’t have any running water or electricity, but I’ve lived there my whole life. He had gotten to the point that you’re talking about he couldn’t chop wood. Right? He couldn’t do a lot of the things that needed to keep him going. Um, but he really understood it. Those were really his values. He was going to probably die in his cabin. Um, but I let him go. Um, because I felt that he, he really did have the capacity to make that trade off and make those decisions.

Tamar: Because of our training and our own experiences, it can be hard  to accept that our priorities, which are often about treating disease or maximizing safety, may fundamentally conflict with those of our patients. But that doesn’t mean they don’t ever have the right to make this type of decision. 

Complexity #2: Physician bias interfering with objective capacity assessment

Margot: We wanted to expand on Dr. Geppert’s last example and speak a bit more broadly about the bias that we as physicians can bring to the capacity assessment. 

Geppert: So the most frequent bias, and you’ve all seen this, is I’m only questioning capacity when the patient doesn’t agree with you, right? So they’re fine until they refuse what you medically recommend or they want to leave AMA or they question you. Um, and then the reverse happens though, and we don’t talk enough about this, which is, you know, you assume a patient’s capacity – not because they’re agreeing with you so much – but because they remind you of somebody like our, you decide they’re incapable cause you don’t like them.

Margot: I’ve found my biases come to the surface during goals-of-care conversations. Like many people, I find CPR gruesome – and having seen a lot of unsuccessful codes, I often find myself wondering whether patients truly appreciate what being full code actually means. A few months ago I had an elderly man with heart failure and end-stage renal failure who came in with symptoms of covid, and wanted everything done. When I explained in detail what CPR would be like, the chaos of chest compressions and lines and meds, told him that he would likely never come off the ventilator if he ever needed intubation, he told me, “just try.” Reflecting on that conversation, I wonder whether he didn’t appreciate the ramifications of his decisions, or whether I was the one off the mark, and maybe I just couldn’t appreciate the reasons he made that choice. A thorough goals-of-care conversation can help us understand each other better, but there’s a certain bridge of experience that’s tough to cross on both sides. And just like Dr Geppert mentioned, this is a bias that comes up for me when patients make a choice that I worry is bad for them. Dr Geppert offers some advice on how to minimize bias you might bring to the table:

Geppert: What I try to teach the residents is figure out what kinds of patients hit your buttons, good and bad, your happy button and your rage button, you know, your fear button and your sad button. Because those are your biases.

Margot: It could also help to have colleagues weigh in, particularly if you’re concerned that you’re not making an impartial decision.

Complexity #3: Treatment over objection

Margot: This next topic is a tough one: no discussion of capacity is complete without a discussion of treatment over objection. It’s often the next step in the conversation after a patient has failed a capacity evaluation.

The most memorable case for me was a patient I cared for who was brought into the emergency room for psychosis, then admitted to medicine because he had a terrible case of cellulitis. Unfortunately he had been off his antipsychotics for a long time, and was acting erratically, sometimes violently. Every time we tried to place an IV he called us murderers, but he didn’t understand that he could lose his leg without our help. These cases of treatment over objection are never easy, even if you have made clear decisions about what needs to be done. Every time I walked by his door I heard him screaming, crying – it was horrible to put him through this, even though he needed the treatment we were giving. 

These are complicated cases, and often require an interdisciplinary approach. Medically, you have to decide whether the benefits of the treatment outweigh the risks you’ll face by potentially sedating or restraining the patient. Legally, you might need a court order; laws differ from state, and differ depending on whether the patient lacks capacity for a psychiatric or a non-psychiatric reason. Ethically, you need to figure out whether it’s worth it. If you’re getting to the point where you’re thinking about treating a patient over their objection, we recommend bringing in your colleagues in psychiatry and ethics to help decide how to move forward.

Complexity #4: Moral distress

Jafar: Yea Margot, I’ve been in these situations too–we can know intellectually that someone doesn’t have capacity, but then carrying out what that means can be really morally distressing.  Screaming, crying, fighting with you–it’s awful, and it really wears on you.  And even just making the decision to take away someone’s personal freedom – declaring someone incapable of making a choice –  just that alone can weigh really heavily on you.  

Geppert: I don’t think we think enough about the moral distress that comes from doing capacity evaluations. Um, you know, the first time I had to go to a psych unit and say this guy was incapable, I mean, I, I couldn’t sleep. I, I just, I still worry that when I die, all of those are going to come back at me. All these people, you know, that I infringed on their freedom and I kept them from going home and you know, um, so I think there’s a lot of moral distress to it that influences your ability to keep doing it and do and, and doing it well. 

Jafar: Look- this is hard, hard stuff.  And it’s hard precisely because it pushes us out of our normal medical algorithms and into some of the deepest places of moral reflection:  What is the right balance of beneficence to autonomy?  How do we protect the most vulnerable but still honor wishes?  Trying to answer these weighty philosophical questions for each individual can be a huge burden to take on:

Geppert: We don’t as a society agree, right? We don’t agree what should happen to people who don’t have anybody. We don’t agree what should happen to people who probably can’t safely be discharged. Um, uh, we don’t agree. You know, what should happen if somebody just wants to leave, even though they’re gonna die. We have a whole spectrum of philosophical, political rights opinions about that, that aren’t medical, that aren’t scientific. Um, and so there’s not a lot of backing for, you know, if you have, you have breast cancer, you need surgery or you need chemotherapy. I mean it’s very different than the rest of what we do. 

Jafar: We know we can’t solve your moral distress.  Sometimes there’s no way to reconcile our personal views with what a patient’s family member or the hospital or a state law dictates, and I’ve walked away from many of these situations with a terrible taste in my mouth.  But we hope that thinking through your difficult cases with the concepts we’ve discussed here offers some clarity, some way to articulate what’s at stake, and why it feels wrong.  For me, leaning into these cases, and talking about them with whoever will listen, has helped me tremendously.  

Conclusion & take-home points

Tamar: Thank you for tuning in to part 2 of our episodes on capacity. The point of this episode was not necessarily to provide clear answers, but to hopefully help foster interest and discussion, so that you maybe feel better prepared to work through these less black and white cases as they come up, and to cope with the emotions they raise. We hope we covered some of the big considerations we face outside the formal decisional capacity assessment, and left some food for thought. Our huge thank you again to Dr Geppert, who had important closing words: 

Geppert: And so you have, you have to be comfortable in the gray and know you’re going to make mistakes either way. Um, and, and that’s what happens in a place where you try to balance beneficence and autonomy and nonmaleficence and respect.

References

• Geppert, C. M., & Abbott, C. (2007). Voluntarism in consultation psychiatry: The forgotten capacity. American Journal of Psychiatry, 164(3), 409-413.
• Grisso, T., Appelbaum, P. S., & Hill-Fotouhi, C. (1997). The MacCAT-T: a clinical tool to assess patients’ capacities to make treatment decisions. Psychiatric services.
• Howe, E. (2009). Ethical aspects of evaluating a patient’s mental capacity. Psychiatry (Edgmont), 6(7), 15.
• Roberts, L. W. (2002). Informed consent and the capacity for voluntarism. American Journal of Psychiatry, 159(5), 705-712.
• https://news.gallup.com/poll/15448/americans-choose-death-over-vegetative-state.aspx