What happens when patient capacity and autonomy diverge?

“I can’t take this, doc. It’s gonna kill me. I can’t. I just can’t,” exclaims my patient with persistent refusal of his medication. My frustration is met with my patient care team’s hesitation to give him the medication with fear of further conflict and possible escalation to violence.  But who’s at fault? Any of us? All of us?

My second patient, lying on the MRI table, shaking his head swiftly in agitation: “That stuff ain’t gonna calm me down. It’s gonna blow up my mind. It’s gonna ruin my life.” Meeting this with a decisive look, I ask the nurse: “Please give the Haldol.” She needed not to reply for me to gather the distress painted over her face. “He’s refusing … I can’t give it. I can’t.”

As doctors, we take an oath to “do no harm,” to prioritize our patient’s wellbeing above all. This, of course, comes in balance with patient autonomy: a patient’s ability to make decisions about his medical treatment without any coercion and in light of being given all the relevant information regarding such treatment, provided that he/she has the capacity to make his own decisions. This decision entails the ability to understand the issue at hand, including the ability to describe the risks and benefits of each option offered as treatment; however, what happens when capacity and autonomy diverge?

Our first patient, used to walking for himself, was hospitalized with a limb-threatening case of osteomyelitis that, if not treated with antibiotics, would ultimately result in amputation of his foot; however, difficulty arose when his underlying untreated mania reared his head. Despite his pressured speech, intermittent yelling, grandiose delusions, he glibly described his younger days as a truck driver. On the surface, he appeared to understand the refusal of antibiotics. However,  as he attempted to leave the hospital ward each day walking, did he truly understand that loss of mobility was the alternative?

Our second patient with altered mental status had waxing and waning pieces of attention, but his sense of humor found no paucity in jokes that cleverly masked his inability to answer some questions. Is his transient alertness enough to refuse pre-medication for an MRI to further understand his complex illness? Our medical decision-making is often met with resistance of staff to administer therapy to refusing patients who are seemingly highly functional. Judgment of capacity presents a gray zone that can put into question the integration of patient’s autonomy and the ideal of beneficence. Psychotic signs and symptoms are not always persistently present and are not always so dramatically portrayed. Coupled with moderate patient mental functionality, this can make judgment of capacity a complex task and ethically jarring in time-sensitive cases.

As physicians, we are taught from an early stage to “just know your patients.” This becomes natural as we spend long hours at the hospital, observing our patients’ many changes and fluctuations. We re-examine frequently, interview family members, analyze the myriad of results to know our patients. As nurses, we are taught to care, to observe, to measure, and to share our concerns with our physician colleagues. We are our patient’s first responders for their pains and their questions. We see them writhe in pain and sleep it off after it’s treated. We’re called to help them feel better, heal better, and understand better. It’s only natural to hesitate to medicate a patient who adamantly screams “no” and had no hints of mania in the minutes leading up to the moment. Complicate this by frequent nursing shift changes and great inflexibility in rescheduling specialized diagnostic tests in the hospital. What is the ethical thing to do? Can the patient refuse his pre-imaging sedative? Can you have intermittent decision-making capacity to refuse your care? At what point can we, as physicians, substitute our decision-making for that of patients’?

Do no harm rings in the back of the mind of everyone involved. Am I doing more harm keeping my patient away from his antibiotics in his manic state? Can I fully diagnose and treat my patient’s alerted mental status without a post-sedative obtained MRI? In what way should I incorporate my staff’s discomfort with my decision to treat my patient whom I believe lacks the medical capacity to make medical decisions?

Stop and listen. We all stop and listen to each other. We talk, and we discuss our views. We explore our opinions and couple them with our experiential and medical knowledge. Should there be concerns for the treatment of a possibly capacity-lacking patient, its urgency should be examined. Its relevance and its effect on our agitated patient should be weighed. Furthermore, our patient’s capacity should be re-evaluated at each point. It’s the careful psychiatric and neurological exam that couples our nurses’ observations with our medical evaluation. Jointly, we can understand our patients’ conditions to be better able to serve them and all the while, do no harm.

Aula Ramo is an internal medicine resident.

Image credit: Shutterstock.com

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