Capacity evaluation for Covid Deniers?

[sloop]

It makes perfect sense that someone can refuse a capacity evaluation. As it is a clinical service and it is their right to do so. As part of that informed consent, you would inform them that refusing the evaluation does not preclude the possibility that the care team or hospital ethics committee may still deem that they do not have medical decision making capacity. But, they definitely have the right to refuse.

And, if that care team has concern about capacity, they should be able to document in a compelling way that the patient does not have that capacity to support their clinical opinion regarding capacity. If a formal evaluation has not been done due to refusal, that is noted and the opinion clearly states what their opinion is based on.

Medical decision making capacity, while a clinical decision, very often has statutes attached to it. I would be very surprised of your state does not have laws regarding this, particularly as it applies to the determination, and later the authorities and duties of the health care agent who has assumed the capacity should the patient be deemed to not have that capacity.

Tell me how you would decide if a person has capacity to refuse a capacity evaluation. Assume that during the informed consent process, they are refusing to participate in any way. Assume that you are a member of the primary team and are trying to assess the capacity.

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[WisNeuro]

Tell me how you would decide if a person has capacity to refuse a capacity evaluation. Assume that during the informed consent process, they are refusing to participate in any way. Assume that you are a member of the primary team and are trying to assess the capacity.

You don't have to prove whether a person has capacity to refuse an evaluation to give them that choice, as legal precedence would state that the capacity is assumed. If you feel that they do not have capacity, the burden to prove that lack of capacity is on you as the evaluator. Whether or not you act legally and ethically by providing informed consent is on you.

 

[sloop]

You don't have to prove whether a person has capacity to refuse an evaluation to give them that choice, as legal precedence would state that the capacity is assumed. If you feel that they do not have capacity, the burden to prove that lack of capacity is on you as the evaluator. Whether or not you act legally and ethically by providing informed consent is on you.

What legal precedence? Keep in mind that statements about the burden of proof in a legal proceeding regarding capacity are completely different than statements that the physician evaluating capacity must assume capacity as a default. In hearings regarding competency to stand trial, a defendant often has a presumption of competence in the sense that incompetence must be proved (this is not always the case, either). That doesn’t mean that when I evaluate competency, the defendant has a right to refuse the evaluation and be presumed competent.

Even if you found a law that said that it is incapacity that must be proven and that capacity is assumed in a hearing regarding capacity, that does not mean that the physician is supposed to assume capacity going into an evaluation.

 

[WisNeuro]

What legal precedence? Keep in mind that statements about the burden of proof in a legal proceeding regarding capacity are completely different than statements that the physician evaluating capacity must assume capacity as a default. In hearings regarding competency to stand trial, a defendant has a presumption of competence in the sense that incompetence must be proved by preponderance of the evidence. That doesn’t mean that when I evaluate competency, the defendant has a right to refuse the evaluation and be presumed competent, nor does it mean that I have to reach my opinion by preponderance of the evidence. I reach my opinion to a “reasonable degree of medical certainty,” which is somewhat similar to preponderance of evidence but also different in many ways.

Even if you found a law that said that it is incapacity that must be proven and that capacity is assumed in a hearing regarding capacity, that does not mean that the physician is supposed to assume capacity going into an evaluation.

Generally speaking, aspects of Grannum v Berard and parts of the federal Patient Self-Determination Act. Additionally, presumed assumed capacity to make medical decisions is explicitly stated in many states laws.

 

[sloop]

Generally speaking, aspects of Grannum v Berard and parts of the federal Patient Self-Determination Act. Additionally, presumed assumed capacity to make medical decisions is explicitly stated in many states laws.

My cursory reading of this is that this is a case where there was no evidence of incapacity submitted at trial. As I mentioned, this seems to relate to the burden of proof in a legal proceeding relating to capacity. Does it actually say anything about how a physician should presume capacity when evaluating a patient, or whether a patient has a right to refuse a capacity evaluation?

Show me a law that says that a physician should be assuming capacity going into a capacity evaluation. Laws stating that capacity must be proved in a legal hearing are not the same thing as this.

Also, what parts of the act? Give me citations to the specific subsections you’re taking about. I’m not going to go read the whole act just because you say something relevant is in it.

 

[Old&InTheWay]

This is essentially the same debate on an endless loop over 4 pages. It would appear that Applebaum and Grisso made the assumption that there would be basic agreement regarding facts and did not think to establish epistemological guidelines to help guide us when there is not. All you can do in these cases is use your best judgment to determine whether keeping someone and treating them against their will is on the whole helpful or harmful to the physical and mental well-being of human you are being asked to assess.

Yes, there are laws that are intended to guide capacity evaluation, but it will always be messy and come down to the judgment of a human physician who has his/her own ethical beliefs/tolerance for risk (just as it is with involuntary holds).

 

[WisNeuro]

https://le.utah.gov/xcode/Title75/Chapter2a/75-2a-S109.html

http://wvethics.org/media/12078/health-care-decisions-act.pdf

Couple examples.

As well as states that have ratified the Uniform Health Care Decisions Act, or similar legislation

 

[sloop]

https://le.utah.gov/xcode/Title75/Chapter2a/75-2a-S109.html

http://wvethics.org/media/12078/health-care-decisions-act.pdf

Couple examples.

As well as states that have ratified the Uniform Health Care Decisions Act, or similar legislation

That Utah statute says nothing about how a physician should go about evaluating capacity, whether they should presume capacity as a default, or whether a patient can refuse a capacity evaluation. That West Virginia statute only says that a person can’t be presumed incapacitated merely based on advanced age or disability. It says nothing about how a physician should actually go about determining capacity other than it should be documented in the medical chart. It also says nothing about a patient’s right to refuse a capacity assessment.

Where does the Health Care Decisions Act speak about these things?

 

[WisNeuro]

That Utah statute says nothing about how a physician should go about evaluating capacity, whether they should presume capacity as a default, or whether a patient can refuse a capacity evaluation. That West Virginia statute only says that a person can’t be presumed incapacitated merely based on advanced age or disability. It says nothing about how a physician should actually go about determining capacity other than it should be documented in the medical chart. It also says nothing about a patient’s right to refuse a capacity assessment.

Where does the Health Care Decisions Act speak about these things?

Cleary stated in Utah statute 75-2a-104

"

(1)	An adult is presumed to have: (a) health care decision making capacity; and (b) capacity to make or revoke an advance health care directive.

 

[sloop]

Cleary stated in Utah statute 75-2a-104

"

(1)	An adult is presumed to have: (a) health care decision making capacity; and (b) capacity to make or revoke an advance health care directive.

By the court, not the physician.

 

[WisNeuro]

By the court, not the physician.

This section further goes over what the provider must do to overcome that presumption. It is clearly talking about services within the healthcare setting. I'd strongly suggest you discuss this with your legal counsel and/or liability insurance.

 

[sloop]

This section further goes over what the provider must do to overcome that presumption. It is clearly talking about services within the healthcare setting. I'd strongly suggest you discuss this with your legal counsel and/or liability insurance.

No, it says nothing substantive about the process of the physician.

(2)

To overcome the presumption of capacity described in Subsection (1)(a), a physician, an APRN, or, subject to Subsection (6), a physician assistant who has personally examined the adult and assessed the adult's health care decision making capacity must: (a) find that the adult lacks health care decision making capacity; (b) record the finding in the adult's medical chart including an indication of whether the adult is likely to regain health care decision making capacity; and (c) make a reasonable effort to communicate the determination to: (i) the adult; (ii) other health care providers or health care facilities that the person who makes the finding would routinely inform of such a finding; and (iii) if the adult has a surrogate, any known surrogate.

All this says is that the law/court has a presumption that people have capacity. In order to overcome that legal presumption (not necessarily the physician’s presumption), a physician has to “find that the adult lacks health care decision making capacity” and do a few things including documenting in the patient’s chart and informing a conscious patient.

Again, I have been very consistent here: this says nothing about the physician’s process of determining capacity. The fact that the law has an assumption does not mandate that individuals have the same assumption in all circumstances. The law will in some cases define nunchucks as a “dangerous weapon.” That does not mandate that your sensei views the nunchucks in your bag as dangerous.

This law does not mandate that a physician have or not have any particular default assumption about the patients they evaluate. It only says that, if they go to court over it, the court is going to have a default presumption of capacity and the physician must have done certain things such as document in the patient’s chart that they have determined that they lack capacity if they expect the court to make the same determination.

Nothing about this precludes a physician from assuming that a patient, regarding whom the treatment team has legitimate concerns regarding capacity, lacks capacity in the absence of any new information. If such a patient refuses to participate in an evaluation and demonstrate competency, nothing precludes the physician from documenting this in the chart, and citing the fact that they couldn’t demonstrate that they could communicate a choice, understand, etc. If it went to court, such a physician could cite these reasons for their determination and would not be in the position described in the above case that you cited. A physician could go into an evaluation presuming incapacity and still fulfill all of their obligations under this law.

 

[WisNeuro]

No, it says nothing substantive about the process of the physician.

(2)

To overcome the presumption of capacity described in Subsection (1)(a), a physician, an APRN, or, subject to Subsection (6), a physician assistant who has personally examined the adult and assessed the adult's health care decision making capacity must: (a) find that the adult lacks health care decision making capacity; (b) record the finding in the adult's medical chart including an indication of whether the adult is likely to regain health care decision making capacity; and (c) make a reasonable effort to communicate the determination to: (i) the adult; (ii) other health care providers or health care facilities that the person who makes the finding would routinely inform of such a finding; and (iii) if the adult has a surrogate, any known surrogate.

All this says is that the law/court has a presumption that people have capacity. In order to overcome that legal presumption (not necessarily the physician’s presumption), a physician has to “find that the adult lacks health care decision making capacity” and do a few things including documenting in the patient’s chart and informing a conscious patient.

Again, I have been very consistent here: this says nothing about the physician’s process of determining capacity. The fact that the law has an assumption does not mandate that individuals have the same assumption in all circumstances. The law will in some cases define nunchucks as a “dangerous weapon.” That does not mandate that your sensei views the nunchucks in your bag as dangerous.

This law does not mandate that a physician have or not have any particular default assumption about the patients they evaluate. It only says that, if they go to court over it, the court is going to have a default presumption of capacity and the physician must have done certain things such as document in the patient’s chart that they have determined that they lack capacity if they expect the court to make the same determination.

No, this states that the physician is subject to this statute, that presumes capacity. And that yes, when it comes to healthcare decision-making, every adult is presumed to have capacity until proven otherwise.

 

[sloop]

No, this states that the physician is subject to this statute, that presumes capacity. And that yes, when it comes to healthcare decision-making, every adult is presumed to have capacity until proven otherwise.

This is incorrect. Subsection 1 is the part that states a presumption of capacity. Subsection 2 is the part that describes the role of a physician in overcoming that presumption. The subject of subsection 1 is implied to be the court, as it is a nonspecific statement of law, and the object is “the adult [patient].” The subject of subsection 2 is “a physician.” The physician is not obligated to subsection 1 like they are to subsection 2.

 

[WisNeuro]

This is incorrect. Subsection 1 is the part that states a presumption of capacity. Subsection 2 is the part that describes the role of a physician in overcoming that presumption. The subject of subsection 1 is implied to be the court, as it is a nonspecific statement of law, and the object is “the adult [patient].” The subject of subsection 2 is “a physician.” The physician is not obligated to subsection 1 like they are to subsection 2.

I'd be willing to put money down on a bet that a lawyer would disagree with your assumptions on this legal matter.

 

[sloop]

I'd be willing to put money down on a bet that a lawyer would disagree with your assumptions on this legal matter.

I could say the same to you. Such a comment doesn’t actually contribute to this discussion.

Aside from the fact that the law you cited does not actually mandate a presumption of competence based on the structure and grammar of the law, your position here makes little practical sense.

Your position seems to be that, if a patient refuses to let a concerned physician talk to them about their decision and evaluate their capacity, the physician has an obligation to just drop the issue and let the patient make whatever medical decision they want. After all, you’re saying that we have to presume capacity and the patient has the right to refuse a capacity evaluation. This means that, if a person on first blush appears to be making a delusion-motivated medical decision that would lead to their death, but refuses to talk to anyone about it, we just have to let them make that decision. That is absolutely crazy, and I think that legislators recognize this. I think that it’s preposterous that you assume that the law requires us to go into such a patient’s room, and throw up our arms after they refuse to talk to us, declaring that they should get to make the decision by default.

Again, I also think that the idea that a patient can refuse a capacity evaluation is absolutely crazy. Yes it’s a medical service, but it’s a medical service that is aimed at determining whether they have the ability to make their own decision about a medical service. How on earth does it make sense that you can be contemplating whether the patient has the ability to make a decision about their medical care, but simultaneously believe that the patient has the right to prevent you from evaluating that? If you’re evaluating capacity, it means that the patient potentially lacks the ability to make a medical decision. If they then refuse to talk to you when you try to evaluate whether they can make that decision, this inherently brings up the question of their capacity to refuse a capacity evaluation. Their capacity to refuse a capacity evaluation is inherently tied to whether or not they have capacity for the initial decision you were going to evaluate. That is, their capacity to refuse the capacity evaluation depends on their understanding, appreciation, etc. of the consequences of refusing a capacity evaluation. The consequences of that decision are effectively include the consequences of the initial medical decision. You’re stuck in a situation where either you have to say that anyone who happens to be sufficiently oppositional to refuse an evaluation should be allowed to make their own medical decision, you wind up in an nihilistic paradox where you’re stuck considering whether the patient has the capacity to refuse and evaluation for capacity to refuse an evaluation for capacity to refuse an evaluation for . . . capacity to make X decision, or you conclude that patients do not have the right to refuse a capacity evaluation.

The first of those possibilities—that you say that anybody who is sufficiently oppositional to refuse evaluation gets to make medical decisions—is completely arbitrary. It means that your right to make medical decisions (or your protections from making uninformed, irrational medical decisions, depending on your ideological leanings and how you look at it), is dependent on a factor that has absolutely nothing with your actual abilities in this regard. Whether you get to make decisions or not is determined primarily by how stubborn you are, rather than how capable you are.

The second of the possibilities is obviously unhelpful for everyone involved.

The only rational way forward is to say that a capacity evaluation is one of the few things that you don’t get to refuse. You can refuse to talk to the evaluator, but they’re going to form an opinion which is going to factor in the fact that you did not participate.

 

[Stagg737]

Appreciation is an important aspect of capacity.

That was my concern with as well. However, the argument that they made was that the patient acknowledged that it was fully possible that they could be wrong and was willing to accept that risk despite labs "proving" an AKI was present. Again, refusal to believe something is not the same as being incapable of understanding.

But most people do not have mental deficits that severely impair their abilities to make decisions.

So does it have to be a severe mental deficit or just a mental deficit? The point I was making was that the definition of "mental deficit" you were using is generalizable to the point of uselessness.

And how exactly did you come to your determination that they were simply unwilling to participate and not unable to participate? Somebody obviously had concerns that the patient may lack capacity, which is why you’re evaluating them. You go in and they don’t say anything, so you determine that they’re volitionally refusing to talk to you. How exactly do you know that? What were your methods?

I would hope that you would enter the room, introduce yourself, and that as a result they would say something like, "I don't want to talk to you" or "I'm not talking about this". How often do you think someone whose capacity is truly in question is going to sit there and not say a word? Let's be realistic.

In the absence of the patient demonstrating that they have it, the reasons for believing they lack capacity will generally prevail by default.

This seems like poor assumption and a blatant disregard for the patient's autonomy, which is kind of the reason we actually evaluate for capacity. I go into capacity evals assuming nothing and evaluate from scratch. If they refuse to participate and do not show obvious signs of lacking capacity, then I have no evidence for or against capacity and giving an opinion that they do or do not have capacity would not only be unethical, but could also be legally problematic as no real assessment was actually performed. If it's obvious, then you shouldn't need to be consulted at all and would still document that they did not demonstrate capacity and let the primary team explain their determination. If it's messy, then consult ethics or legal like I previously said. Regardless, I'm certainly not putting my neck/license out there by saying a patient lacks capacity because they wouldn't talk to me.

It says nothing about how a physician should actually go about determining capacity other than it should be documented in the medical chart. It also says nothing about a patient’s right to refuse a capacity assessment.

If a patient refuses to participate and you write that they are incapacitated because of this, then they undergo a procedure and later sue do you really think your "assessment" will hold up in court?

 

[Mass Effect]

Yes, capacity is the default position, but by the time that you’re evaluating it formally, somebody has concerns that they actually lack capacity.

More like, someone placed a CYA consult.

 

[Mass Effect]

All you can do in these cases is use your best judgment to determine whether keeping someone and treating them against their will is on the whole helpful or harmful to the physical and mental well-being of human you are being asked to assess.

Well no. This is exactly the problem, not the solution. You don't get to decide what is helpful or harmful. All you get to do is determine whether or not the PATIENT understands what's helpful or harmful. People with capacity get to decide what happens to their own bodies, not us.

 

[Mass Effect]

By the court, not the physician.

Umm, physicians are bound by laws, just like courts.

 

[Mass Effect]

No, it says nothing substantive about the process of the physician.

(2)

To overcome the presumption of capacity described in Subsection (1)(a), a physician, an APRN, or, subject to Subsection (6), a physician assistant who has personally examined the adult and assessed the adult's health care decision making capacity must: (a) find that the adult lacks health care decision making capacity; (b) record the finding in the adult's medical chart including an indication of whether the adult is likely to regain health care decision making capacity; and (c) make a reasonable effort to communicate the determination to: (i) the adult; (ii) other health care providers or health care facilities that the person who makes the finding would routinely inform of such a finding; and (iii) if the adult has a surrogate, any known surrogate.

All this says is that the law/court has a presumption that people have capacity. In order to overcome that legal presumption (not necessarily the physician’s presumption), a physician has to “find that the adult lacks health care decision making capacity” and do a few things including documenting in the patient’s chart and informing a conscious patient.

Again, I have been very consistent here: this says nothing about the physician’s process of determining capacity. The fact that the law has an assumption does not mandate that individuals have the same assumption in all circumstances. The law will in some cases define nunchucks as a “dangerous weapon.” That does not mandate that your sensei views the nunchucks in your bag as dangerous.

This law does not mandate that a physician have or not have any particular default assumption about the patients they evaluate. It only says that, if they go to court over it, the court is going to have a default presumption of capacity and the physician must have done certain things such as document in the patient’s chart that they have determined that they lack capacity if they expect the court to make the same determination.

Nothing about this precludes a physician from assuming that a patient, regarding whom the treatment team has legitimate concerns regarding capacity, lacks capacity in the absence of any new information. If such a patient refuses to participate in an evaluation and demonstrate competency, nothing precludes the physician from documenting this in the chart, and citing the fact that they couldn’t demonstrate that they could communicate a choice, understand, etc. If it went to court, such a physician could cite these reasons for their determination and would not be in the position described in the above case that you cited. A physician could go into an evaluation presuming incapacity and still fulfill all of their obligations under this law.

Dude...

 

[Stagg737]

Addressing the original question:

This is quite an interesting situation and I think the essential information that would help provide an adequate response lies in the collateral from family and what the patient's chronic baseline is. If this was pre-COVID and the patient were in this exact situation, what would she have done? If this were the flu and not COVID, what would she do now? A month ago? 2 years ago? Given what I've read I don't think there is really a completely correct answer here and that the evaluation largely depends on which bioethical principles are prioritized. Some points that I believe are still salient to the ongoing conversation:

I'm actually curious if 'substantial distortion of reality' is not a delusion. Of course you could argue that religious beliefs for example can be substantial distortions of reality and we don't argue they are delusions, but I do not think this is the case with covid conspiracy theories. They aren't religious or even cultural beliefs and this distinction here is important.

I would argue strongly that there is a shared culture among many COVID deniers. Whether the beliefs of this culture rise to a diagnosable disorder is a different question.

There doesn't seem to be a durable change in mental status that would lead me to believe they had an underlying psychiatric condition, one that would have led them to make a different decision if they have not had said condition.

I agree with most of what Flowrate said on the first page, and this sums up my thoughts nicely. From what's described, it sounds like this is not an acute change

I think in this scenario strong documentation comes into play, also maybe even holding a family meeting would be a great idea.

Again, I think the collateral from family is essential. What was the patient's understanding of her medical problems before this hospitalization and before COVID? Does she take care of herself? Has she had multiple previous hospitalizations? More info is needed before I'd actually make provide an opinion in the EMR. It sounds like the family wants the physicians to make a decision to force treatment because they are worried about her outcome.

This was a change from baseline in terms of their view toward healthcare professionals. So the question became as others on this thread have mentioned, are delusions such these where it's illogical and there's more than ample evidence it's untrue, a mental illness? And if yes, is it inhibiting her ability to grasp the seriousness of her condition?

I'm confused on what her actual baseline is. Earlier family said that patient is currently at baseline mentation. Is the change in opinion toward healthcare professionals acute or something that can directly be attributed to some form of cognitive impairment? Or has she changed her opinion on healthcare teams because of how COVID has been handled? Was this a gradual change over months or years or can a clear point in time when her opinion changed be identified? Imo, how we define "baseline" is also important as someone's baseline can easily shift over months or years to something completely different, so her change in opinion toward healthcare professionals (or maybe just being hospitalized) may not be a change from baseline, maybe that is the new baseline?

I honestly don't think the bolded is all that relevant. People believe lies all the time, some bigger than others, so an illogical belief on it's own doesn't warrant a mental illness. The second part is more relevant, as the real question is "does this patient have a delusion/belief/insert-your-own-word which impairs her ability to cognitively function at a normal baseline?" If yes, then does that cognitive dysfunction change the decision that the patient would have at baseline? If yes, then she's lacking capacity. If no, then she's got it.

From what it sounds like she has had a gradual, chronic change in her baseline beliefs but has been functioning adequately at that new baseline. It also sounds like her presentation at the hospital was at or very near that functional baseline, so I would have a hard time stating she lacks capacity given all the information shared. That being said, collateral from family could certainly change that opinion depending on the situation. I think the best argument for lacking capacity is whether she can appreciate how the illness applies to her, and if she is truly incapable of understanding that it is possible for her co-morbidities and current state to worsen, then I think one could reasonably make the argument that she lacks capacity and I would most likely agree with them.

tl: dr - She probably had capacity but I'd get a lot more info from family. Thanks for sharing, this has been a great thread.

 

[sloop]

Umm, physicians are bound by laws, just like courts.

Physicians are not bound by clauses in laws that are general statements about assumptions of the law. In general, parts of laws that say “it is assumed” or “X means” or “X is presumed to” are statements about how the law is to be interpreted by the courts.

The parts of laws that imply actual obligations either on people in general or on specific people tend to take the form of “X shall” or “it shall be a violation of this subsection if X.”

Many aspects of the law detail things about legal procedure in court hearings. Those are actually not relevant to those who are not finders or fact or law in the relevant legal proceedings. Our law also says criminal defendants are innocent until a proven guilty in a court of law. That does not mean that individual people are obligated to find a person innocent if they haven’t been convicted. A standard of proof may also be cited in the law with respect to hearings about a particular issue, but that also doesn’t mean that is the relevant standard for a physician evaluating the issue.

The thing with the law is that it is critically important how a statute is phrased and to whom the statute specifically imposes obligations.

 

[Stagg737]

Your position seems to be that, if a patient refuses to let a concerned physician talk to them about their decision and evaluate their capacity, the physician has an obligation to just drop the issue and let the patient make whatever medical decision they want. After all, you’re saying that we have to presume capacity and the patient has the right to refuse a capacity evaluation. This means that, if a person on first blush appears to be making a delusion-motivated medical decision that would lead to their death, but refuses to talk to anyone about it, we just have to let them make that decision. That is absolutely crazy, and I think that legislators recognize this. I think that it’s preposterous that you assume that the law requires us to go into such a patient’s room, and throw up our arms after they refuse to talk to us, declaring that they should get to make the decision by default.

Wat? I don't think anyone is making that argument and it's a ridiculous interpretation of the argument being made.

If a patient refuses to participate, you document that and recommend that the primary team consult ethics and the legal department. You tell the patient that you are recommending that and inform them that they will have to wait to speak with the legal team. Most of the time the patient will start cooperating, but if they don't then everyone maintains a holding pattern until the lawyers step in.

Again, you don't just assume they have capacity, but you also don't assume it's lacking. I think it's both unethical and dangerous to opine that a patient lacks capacity because they don't want to talk to you. Though it would definitely make dealing with antisocial patients a lot easier.

 

[Mass Effect]

Addressing the original question:

This is quite an interesting situation and I think the essential information that would help provide an adequate response lies in the collateral from family and what the patient's chronic baseline is. If this was pre-COVID and the patient were in this exact situation, what would she have done? If this were the flu and not COVID, what would she do now? A month ago? 2 years ago? Given what I've read I don't think there is really a completely correct answer here and that the evaluation largely depends on which bioethical principles are prioritized. Some points that I believe are still salient to the ongoing conversation:



I would argue strongly that there is a shared culture among many COVID deniers. Whether the beliefs of this culture rise to a diagnosable disorder is a different question.



I agree with most of what Flowrate said on the first page, and this sums up my thoughts nicely. From what's described, it sounds like this is not an acute change



Again, I think the collateral from family is essential. What was the patient's understanding of her medical problems before this hospitalization and before COVID? Does she take care of herself? Has she had multiple previous hospitalizations? More info is needed before I'd actually make provide an opinion in the EMR. It sounds like the family wants the physicians to make a decision to force treatment because they are worried about her outcome.



I'm confused on what her actual baseline is. Earlier family said that patient is currently at baseline mentation. Is the change in opinion toward healthcare professionals acute or something that can directly be attributed to some form of cognitive impairment? Or has she changed her opinion on healthcare teams because of how COVID has been handled? Was this a gradual change over months or years or can a clear point in time when her opinion changed be identified? Imo, how we define "baseline" is also important as someone's baseline can easily shift over months or years to something completely different, so her change in opinion toward healthcare professionals (or maybe just being hospitalized) may not be a change from baseline, maybe that is the new baseline?

I honestly don't think the bolded is all that relevant. People believe lies all the time, some bigger than others, so an illogical belief on it's own doesn't warrant a mental illness. The second part is more relevant, as the real question is "does this patient have a delusion/belief/insert-your-own-word which impairs her ability to cognitively function at a normal baseline?" If yes, then does that cognitive dysfunction change the decision that the patient would have at baseline? If yes, then she's lacking capacity. If no, then she's got it.

From what it sounds like she has had a gradual, chronic change in her baseline beliefs but has been functioning adequately at that new baseline. It also sounds like her presentation at the hospital was at or very near that functional baseline, so I would have a hard time stating she lacks capacity given all the information shared. That being said, collateral from family could certainly change that opinion depending on the situation. I think the best argument for lacking capacity is whether she can appreciate how the illness applies to her, and if she is truly incapable of understanding that it is possible for her co-morbidities and current state to worsen, then I think one could reasonably make the argument that she lacks capacity and I would most likely agree with them.

tl: dr - She probably had capacity but I'd get a lot more info from family. Thanks for sharing, this has been a great thread.

Seems she's gone down the QAnon rabbit hole. Prior to that, she was at a baseline that accepted medical advice. Has been hospitalized before due to co-morbidities and always allowed for hospitalization and followed doctor's recommendations until all this. She believes Covid was invented and fabricated as a plot against Trump and that it doesn't really exist.

 

[Mass Effect]

Physicians are not bound by clauses in laws that are general statements about assumptions of the law.

But it's not an "assumption of the law". The link is the law itself. It's stated in black and white and physicians most certainly ARE bound by those states as they are in fact law. It says clear as day that the presumption is that patients have capacity and that a physician "must find" they lack capacity. I don't know how much clearer it could possibly be.

In general, parts of laws that say “it is assumed” or “X means” or “X is presumed to” are statements about how the law is to be interpreted by the courts.

Dude, the law is written on the state government website. This isn't some third party telling us about it. Using that line of thinking is very surely going to get you sued for malpractice, but more importantly it scares me that you're interpreting the law this way and making these decisions on behalf of patients. It really sounds like you're grasping to override autonomy.

 

[sloop]

Wat? I don't think anyone is making that argument and it's a ridiculous interpretation of the argument being made.

If a patient refuses to participate, you document that and recommend that the primary team consult ethics and the legal department. You tell the patient that you are recommending that and inform them that they will have to wait to speak with the legal team. Most of the time the patient will start cooperating, but if they don't then everyone maintains a holding pattern until the lawyers step in.

Again, you don't just assume they have capacity, but you also don't assume it's lacking. I think it's both unethical and dangerous to opine that a patient lacks capacity because they don't want to talk to you. Though it would definitely make dealing with antisocial patients a lot easier.

Two statements that have definitely been made by WisNeuro:

1) Physicians should presume people to have capacity
2) Patients are entitled to refuse an evaluation for capacity

Assume a hypothetical person, person X, actually lacks capacity, and has shown signs that they may lack capacity. According to (1) the evaluating physician assumes they have capacity, but tries to evaluate for capacity. According to (2) the patient refuses an evaluation. As a result, according to (1) the patient is opined to have capacity. Therefore, person X, who actually lacks capacity and shows signs that they may lack capacity, is allowed to make their own medical decisions. This is the consequence of the two beliefs listed above in concert.

 

[Stagg737]

Two statements that have definitely been made by WisNeuro:

1) Physicians should presume people to have capacity
2) Patients are entitled to refuse an evaluation for capacity

Assume a hypothetical person, person X, actually lacks capacity, and has shown signs that they may lack capacity. According to (1) the evaluating physician assumes they have capacity, but tries to evaluate for capacity. According to (2) the patient refuses an evaluation. As a result, according to (1) the patient is opined to have capacity. Therefore, person X, who actually lacks capacity and shows signs that they may lack capacity, is allowed to make their own medical decisions. This is the consequence of the two beliefs listed above in concert.

When taken as absolutes together, then yes, you're correct. However, the assumption that a person has capacity does not mean that our medical opinion will be that they have it if they refuse assessment. In that case, you would state that it cannot be determined as you can't evaluate them. So while I would assume that someone has capacity at baseline, that is certainly not going to be my official opinion if they refuse evaluation and I'd punt to the legal team to determine the next steps.

 

[sloop]

But it's not an "assumption of the law". The link is the law itself. It's stated in black and white and physicians most certainly ARE bound by those states as they are in fact law. It says clear as day that the presumption is that patients have capacity and that a physician "must find" they lack capacity. I don't know how much clearer it could possibly be.

It is presumed by who though?

You don’t get it. Statutes are interpreted strictly. You don’t just get to take any statement in a law that, as a whole, mentions physicians and claim that it is obligating physicians to do something.

Here is the context of that law:

As a general rule, people are allowed to make their own decisions. Under some circumstances, however, people are unable to make their own medical decisions. This law is outlining the set of circumstances under which the courts will recognize incapacity. It is laying out the assumption that the courts will presume capacity until a physician has determined otherwise, documented in the chart, etc.

It does not mandate that a physician presume capacity as a part of his or her clinical process. As I said, if a law intends to obligate someone in particular, it will make this clear. The law does not say that a physician shall presume capacity.

If I said that that it is presumed that my car is safe to drive until a mechanic says it’s not, do you think that means that I believe my mechanic should presume that my car is safe to drive? No. They’re supposed to examine the car and make sure that the parts that are relevant to safety (brakes, tires, etc.) appear to be functioning normally. This is literally the form of this law. The law will presume capacity until a physician declares otherwise, and that physician should to several things including document in the chart and inform the incapacitated patient.

Dude, the law is written on the state government website. This isn't some third party telling us about it. Using that line of thinking is very surely going to get you sued for malpractice, but more importantly it scares me that you're interpreting the law this way and making these decisions on behalf of patients. It really sounds like you're grasping to override autonomy.

You can think whatever you want. I don’t think this law is about the thing you think it is.

 

[Stagg737]

Seems she's gone down the QAnon rabbit hole. Prior to that, she was at a baseline that accepted medical advice. Has been hospitalized before due to co-morbidities and always allowed for hospitalization and followed doctor's recommendations until all this. She believes Covid was invented and fabricated as a plot against Trump and that it doesn't really exist.

How long has she been in the burrow? Did she just start watching YouTube videos one day and get trapped or was it over several weeks to months? Did she have a penchant of rigidity in her beliefs previously? Perhaps most importantly, is she still following physician recommendations for her other medical problems? If she's become completely distrusting of everyone or most of her physicians, I think you've got more grounds to say lacking capacity as it indicates a more significant and global change from her baseline (assuming she's been trusting other physicians somewhat recently). If she's otherwise cooperative and the disagreement with doctors is solely this admission and specifically for being admitted for COVID, Idk that you could really strongly argue that she lacks capacity unless you argue that all COVID deniers are delusional and lacking capacity.

 

[Mass Effect]

It is presumed by who though?

You don’t get it. Statutes are interpreted strictly. You don’t just get to take any statement in a law that, as a whole, mentions physicians and claim that it is obligating physicians to do something.

Here is the context of that law:

As a general rule, people are allowed to make their own decisions. Under some circumstances, however, people are unable to make their own medical decisions. This law is outlining the set of circumstances under which the courts will recognize incapacity. It is laying out the assumption that the courts will presume capacity until a physician has determined otherwise, documented in the chart, etc.

It does not mandate that a physician presume capacity as a part of his or her clinical process. As I said, if a law intends to obligate someone in particular, it will make this clear. The law does not say that a physician shall presume capacity.

If I said that that it is presumed that my car is safe to drive until a mechanic says it’s not, do you think that means that I believe my mechanic should presume that my car is safe to drive? No. They’re supposed to examine the car and make sure that the parts that are relevant to safety (brakes, tires, etc.) appear to be functioning normally. This is literally the form of this law. The law will presume capacity until a physician declares otherwise, and that physician should to several things including document in the chart and inform the incapacitated patient.


You can think whatever you want. I don’t think this law is about the thing you think it is.

I don't think it's that I "don't get it". I think that several of us have now told you that your interpretation is wrong and your response is that you're more informed than we are. I still believe that's wrong. But you do you. It still terrifies me that you're making these decisions for patients.

 

[Mass Effect]

How long has she been in the burrow? Did she just start watching YouTube videos one day and get trapped or was it over several weeks to months?

This isn't my patient so I don't know. But I don't think the rate of onset matters if she's been this way for a while which was my read of the situation. This isn't something that just happened last Saturday. I got the impression it happened before the 2020 election sometime.

Did she have a penchant of rigidity in her beliefs previously? Perhaps most importantly, is she still following physician recommendations for her other medical problems? If she's become completely distrusting of everyone or most of her physicians, I think you've got more grounds to say lacking capacity as it indicates a more significant and global change from her baseline (assuming she's been trusting other physicians somewhat recently). If she's otherwise cooperative and the disagreement with doctors is solely this admission and specifically for being admitted for COVID, Idk that you could really strongly argue that she lacks capacity unless you argue that all COVID deniers are delusional and lacking capacity.

I think that's kind of the point. As this wasn't my patient, I can't give more specifics than I already have, but I think the underlying issue here is are people who deny something that's proven by facts and data guilty of having a fixed false belief that wed ordinarily call a delusion? There are good arguments on both sides and I agree with what you said before that it doesn't seem there's a right or wrong answer here.

 

[sloop]

When taken as absolutes together, then yes, you're correct. However, the assumption that a person has capacity does not mean that our medical opinion will be that they have it if they refuse assessment. In that case, you would state that it cannot be determined as you can't evaluate them. So while I would assume that someone has capacity at baseline, that is certainly not going to be my official opinion if they refuse evaluation and I'd punt to the legal team to determine the next steps.

Logically, I believe that if you cannot demonstrate capacity, you lack capacity.

1) Capacity is binary. You either have capacity for a decision or you don’t. There is no such thing as “kind of” having capacity.
2) Capacity is defined by the ability to do a certain set of things (appreciate, understand, etc.)
3) Restatement of (2): You have capacity if and only if you are able to do the set of things that defines capacity.
4) Given (1) and (3), if one is unable to do any one of the set of things that defines capacity, they lack capacity.
5) We cannot know the motives of people who don’t tell us or show us.
6) Given (5), unwillingness to demonstrate those things necessary for capacity is functionally indisinguishable from inability to do those things.
7) Given (4) and (6), those who cannot demonstrate the ability to do those things necessary for capacity must be viewed to lack capacity.

 

[sloop]

I don't think it's that I "don't get it". I think that several of us have now told you that your interpretation is wrong and your response is that you're more informed than we are. I still believe that's wrong. But you do you. It still terrifies me that you're making these decisions for patients.

You really think this law tells physicians that they need to go into a capacity evaluation assuming that the patient has capacity? I think that’s insane. I also have no idea how that’s enforceable. Also, where do you start that timeline? Are you to presume incapacity the moment you enter the patient room? When you get the consult? After you’ve talked to the patient but before taking to collateral? What if, before you interview the patient, the nurse tells you that they’ve been talking about all sorts of crazy **** like that they’re going to join Satan? At what point exactly do you believe it’s fair to no longer presume capacity.

Personally, when I evaluate someone for capacity or competency, I assume nothing either way. I let the evidence guide me. When I see someone for a competency evaluation, if the nursing notes show that they’re spending their days rocking and mumbling incoherent religious phrases under their breath, then they refuse to talk to me, I still have to write a report. My report is written to a “reasonable degree of medical certainty,” which is basically to say “in my medical opinion, what is more likely true than not true?” In such a situation, assuming I had no additional information, I’m opining IST. I’m not saying some bull**** like “well, I can’t really tell for sure.” Nobody likes that type of opinion. You know who really hate that type of opinion? Judges. As a general rule, judges hate it when you take some nonsense, waffling stance because they’re in no better position to figure it out than you are.

 

[WisNeuro]

Point of clarification regarding presumption of capacity. You presume that the patient has capacity until you have compelling evidence that they do not. This is what the law, ethics, every provider guide that I have ever seen on capacity states. Ideally, this includes personal evaluation of the patient, but this will not always be the case, either by refusal from the patient, or extenuating circumstance. This does not change the clear fact that capacity is presumed.

 

[WisNeuro]

Also, another point of clarification, in which I believe someone clearly misunderstood something earlier. I never claimed that a patient refusing a capacity evaluation does not mean that they are deemed to have capacity. Merely that they do not have to participate. In some cases, these means that I do not have enough information to make a clear opinion either way. In other cases, the chart review and the medical team have provided enough info that I do believe that there is a lack of capacity. And, within the informed consent, I can make that known to the patient. In essence, I tell them that the evaluation is actually their chance to "prove it" as the treatment team believes that they do not have capacity for that decision.

 

[sloop]

Point of clarification regarding presumption of capacity. You presume that the patient has capacity until you have compelling evidence that they do not. This is what the law, ethics, every provider guide that I have ever seen on capacity states. Ideally, this includes personal evaluation of the patient, but this will not always be the case, either by refusal from the patient, or extenuating circumstance. This does not change the clear fact that capacity is presumed.

I agree that it is presumed in the sense that nobody is assuming that every patient in the hospital lacks capacity. As a practical matter, though, unless you get a complete bull**** consult, somebody has some reason to suspect that the patient doesn’t have capacity. So, in reality, for the most part, I go into every capacity evaluation assuming nothing. At the point that somebody has requested an evaluation of capacity, there is usually at least some evidence that they lack capacity. This is why I think that generally, if the patient does not talk to you, they don’t have capacity. Usually somebody has heard them say something irrational about their care, or the choice they’ve stated is prime facie irrational in the sense that it has no discernible benefits and substantial risks. In such a circumstance, talking to the patient is really, in some sense, their chance to prove that they actually do have capacity despite initially appearing otherwise.

I agree that if you’re going in with literally no information, you presume people have capacity and don’t just question the capacity of every patient that comes through the door. However, unless you got a consult that was totally and completely baseless, I think that the mere concerns that people have about the situation are enough to shift the evidentiary situation to the point that you’re at least agnostic or often are tilting towards lacking capacity.

 

[WisNeuro]

I agree that it is presumed in the sense that nobody is assuming that every patient in the hospital lacks capacity. As a practical matter, though, unless you get a complete bull**** consult, somebody has some reason to suspect that the patient doesn’t have capacity. So, in reality, for the most part, I go into every capacity evaluation assuming nothing. At the point that somebody has requested an evaluation of capacity, there is usually at least some evidence that they lack capacity. This is why I think that generally, if the patient does not talk to you, they don’t have capacity. Usually somebody has heard them say something irrational about their care, or choice they’ve stated is prime facie irrational in the sense that it has no discernible benefits and substantial risks. In such a circumstance, talking to the patient is really, in some sense, their chance to prove that they actually do have capacity despite initially appearing otherwise.

I agree that if you’re going in with literally no information, you presume people have capacity and don’t just question the capacity of every patient that comes through the door. However, unless you got a consult that was totally and completely baseless, I think that the mere concerns that people have about the situation are enough to shift the evidentiary situation to the point that you’re at least agnostic or often are tilting towards lacking capacity.

I personally don't give a **** if someone has reason to suspect that the patient doesn't have capacity. About 70% of the time it's usually something like the patient is a pain in the a** and the treating doctor has spent a total of 10 seconds explaining difficult concepts to someone with limited health literacy. And, when they are actually engaged in conversation and have things explained in layment's terms, the patient actually agrees with the treatment team. Or, the patient has a neurological condition that makes their speech very slow and very low volume and the treatment team never took the time ti actually communicate with the patient. This was the norm, not the exception. In my experience, the treatment teams assumption is incorrect far more often than it is correct, and usually by easily discoverable factors.

If you ever said "the patient did not talk to me, so they don't have capacity" in court, you would get absolutely destroyed. You find actual information to make your opinion, not that garbage.

And no, I never enter the situation tilting towards lacking capacity, as that is completely contrary to the point of capacity evaluations, and frankly, unethical.

 

[sloop]

I personally don't give a **** if someone has reason to suspect that the patient doesn't have capacity. About 70% of the time it's usually something like the patient is a pain in the a** and the treating doctor has spent a total of 10 seconds explaining difficult concepts to someone with limited health literacy. And, when they are actually engaged in conversation and have things explained in layment's terms, the patient actually agrees with the treatment team. Or, the patient has a neurological condition that makes their speech very slow and very low volume and the treatment team never took the time ti actually communicate with the patient. This was the norm, not the exception. In my experience, the treatment teams assumption is incorrect far more often than it is correct, and usually by easily discoverable factors.

If you ever said "the patient did not talk to me, so they don't have capacity" in court, you would get absolutely destroyed. You find actual information to make your opinion, not that garbage.

And no, I never enter the situation tilting towards lacking capacity, as that is completely contrary to the point of capacity evaluations, and frankly, unethical.

I disagree. I think there are many situations where the medical chart points to a major cognitive issue that is interfering with capacity. In any case, what I am telling you is that I base my determinations on the evidence I see, not on some arbitrary presupposition.

I’d be happy to testify in court about any of my opinions. “The patient did not talk to me” can be perfectly acceptable evidence for why they lack capacity in many circumstances. My opinions are to a reasonable degree of medical certainty. I don’t have to be absolutely certain of every opinion I make. I look at the evidence and see where it leads. If I’m 51% confident that someone lacks capacity, that is my opinion. Same with competency. “Patient would not talk to me about his decision” plus almost any piece of information that would tend to suggest incapacity, even slightly, could get me to that level of certainty.

Someone could grill me on “isn’t it possible that they actually have capacity and just don’t want to talk to you?” all they want. My response is “yes, that is possible, but that is not my opinion because the available evidence, taken together, suggests that he lacks capacity and, when I met with him, he was unable to verbalize a choice, demonstrate understanding of the decision, appreciate the consequences of the decision, or make a rational choice.”

 

[Stagg737]

I think the underlying issue here is are people who deny something that's proven by facts and data guilty of having a fixed false belief that wed ordinarily call a delusion?

Tbh, I don't think this really matters in most cases of capacity and matters minimally here. My questions would be: Does she understand she's sick for whatever reason? If no, does she understand that she can be very wrong, and that the risks of being wrong are something she is able to verbalize and willing to accept? If she does, she likely has capacity, but obviously there are nuances to every situation. What matters isn't really her beliefs, it's whether or not she is capable of understanding that specific situation, the possible outcomes, and whether it's possible they can apply to her if her belief is wrong. In this case, it sounds like she's been through the pna rodeo enough times to know the general points, it's just a matter of if she can appreciate and accept the risks if her beliefs are wrong.

Logically, I believe that if you cannot demonstrate capacity, you lack capacity.

1) Capacity is binary. You either have capacity for a decision or you don’t. There is no such thing as “kind of” having capacity.
2) Capacity is defined by the ability to do a certain set of things (appreciate, understand, etc.)
3) Restatement of (2): You have capacity if and only if you are able to do the set of things that defines capacity.
4) Given (1) and (3), if one is unable to do any one of the set of things that defines capacity, they lack capacity.
5) We cannot know the motives of people who don’t tell us or show us.
6) Given (5), unwillingness to demonstrate those things necessary for capacity is functionally indisinguishable from inability to do those things.
7) Given (4) and (6), those who cannot demonstrate the ability to do those things necessary for capacity must be viewed to lack capacity.

I agree with your first 3 points and basically the 4th and 5th points, I completely disagree with number 6 though and I think number 7 is just ridiculous. Take Schrodinger's cat example without the physics. Cat goes in the box, a button is pushed, the cat is either dead or alive but we cannot know until we evaluate the box. You don't get to say, "Well, I can't look in the box, but the cat can't prove it's alive, so it must be dead." That's just stupid. It's the same thing here. Just because you don't know a patient has capacity, does not mean they are lacking it.

Unable to demonstrate =/= lack of. Frankly I find your argument that the two are equal as frightening as it is wrong.

 

[sloop]

Tbh, I don't think this really matters in most cases of capacity and matters minimally here. My questions would be: Does she understand she's sick for whatever reason? If no, does she understand that she can be very wrong, and that the risks of being wrong are something she is able to verbalize and willing to accept? If she does, she likely has capacity, but obviously there are nuances to every situation. What matters isn't really her beliefs, it's whether or not she is capable of understanding that specific situation, the possible outcomes, and whether it's possible they can apply to her if her belief is wrong. In this case, it sounds like she's been through the pna rodeo enough times to know the general points, it's just a matter of if she can appreciate and accept the risks if her beliefs are wrong.




I agree with your first 3 points and basically the 4th and 5th points, I completely disagree with number 6 though and I think number 7 is just ridiculous. Take Schrodinger's cat example without the physics. Cat goes in the box, a button is pushed, the cat is either dead or alive but we cannot know until we evaluate the box. You don't get to say, "Well, I can't look in the box, but the cat can't prove it's alive, so it must be dead." That's just stupid. It's the same thing here. Just because you don't know a patient has capacity, does not mean they are lacking it.

Unable to demonstrate =/= lack of. Frankly I find your argument that the two are equal as frightening as it is wrong.

How can you maintain this position without jeopardizing the entire concept that a person can lack capacity? You’re saying that lacking capacity and being unable to demonstrate it are not the same thing. Let’s accept that proposition as true for the sake of argument. How are you going to distinguish them? How do you know that all of the people you have opined as lacking capacity are not just people with capacity who haven’t been able to demonstrate it?

 

[Desired Member]

it absolutely DOES matter. If the person doesn't have a mental disorder, then it doesn't matter whether they can't appreciate the severity of their condition or not. The whole point of decision-making capacity (and the reason why psychiatrists and psychologists are brought in to weigh on this question) is that we presume people have the ability to make decisions unless their is a reason to believe that their mental functions are impaired to the extent that they cannot. If you don't have a mental illness, neurocognitive disorder, or intellectual disability, then you still have decision making capacity even if you are unable to check all the boxes of the Appelbaum and Grisso criteria. Put simply, it is NOT enough to not communicate, understand, appreciate, and/or reason, but this deficit has to be due to a mental impairment. If the reason for the deficit is a cultural belief (i.e. an overvalued idea) then you have no justification for denying that patient their autonomy. decision-making capacity is fundamentally rooted in autonomy, because the whole point of evaluating capacity is to promote autonomy. If you allow someone to make a decision that they would have not made if they did have capacity, then you are depriving them of their autonomy as the decision is being fueled by delirium/psychosis/dementia etc. On the other hand, if someone has a deep personal conviction that is fundamental to their identity (for example being a QAnon believer who thinks COVID is a hoax to take down Trump etc), then that pt's beliefs about their illness, and subsequent decisions, even if they fly in the face of medical reality, are tied to that patient's autonomy and you have no justification to deny them their right to make decisions you disagree with if they aren't deemed to be psychotic.


It is unfortunate how poorly taught capacity evaluations are that so many psychiatrists do not appreciate this basic point.

ETA:

From Scott Kim's Evaluation of Capacity to Consent to Treatment and Research. Oxford: OUP, 2010

What about personality disorders/traits? I had a patient who was displaying NPD traits who thought the doctors wanted to keep him to make more money and thought that he was sick but would ultimately be fine if he went home. He did not otherwise have any depression, anxiety, psychosis, etc. I realize you can't answer specifically but wondering what your general thoughts are on personality disorders and capacity evals

 

[Desired Member]

I don't think I communicated clearly above. I think the abnormal affective state and impaired reality testing is the root cause rather than the end result of true delusions. And I don't think that people who believe in false conspiracy theories develop impaired reality testing, or an increased sense of salience, etc. However they may as a group be more prone to jumping to conclusions (and I believe there's some research to back this up).

Perhaps a reasonable analogy is the idea of "sadness." It could be due to an underlying biochemical depression, or it could be the result of having suffered a recent loss. Behaviorally, the sadness may appear the same in both cases and may cause the same amount of distress in the moment. However, in the former, the sadness is not serving any beneficial purpose to the patient, whereas in the latter, sadness may facilitate the processing of grief and loss.

Perhaps one could argue that someone who holds a false belief due to cognitive error has the potential to learn from their mistake, which may actually be beneficial to the individual in the long run.

I don't have all these ideas fully fleshed out, mostly just thinking out loud here.

Some of what you are saying is over my head but I'm trying to understand.

"Perhaps a reasonable analogy is the idea of "sadness." It could be due to an underlying biochemical depression, or it could be the result of having suffered a recent loss. " I didn't think we knew enough to biochemically differentiate between depression occurring randomly vs immediately after a loss? Maybe I'm missing the point?

I would argue that we have no idea why psychosis/mania occurs and we have just identified constellations of symptoms that tend to occur together and pieced together some risk factors. We don't know whether an abnormal affective state CAUSES delusions, they just co occur sometimes. And aren't delusions just evidence of impaired reality testing?

"And I don't think that people who believe in false conspiracy theories develop impaired reality testing" - Kind of related point, I would argue that in this lady's case (e.g. a person appears delusional without any disorganized speech/behavior or hallucinations), it's impossible to know whether they are actually delusional or know they have probably been wrong this whole time and are refusing to admit it, e.g. narcisissm.

I was taught that a delusion is a fixed , false belief. This lady does not believe COVID is real; since we have proof that COVID is real, her belief is false. Her belief is fixed - she won't even entertain the idea that COVID is real. Therefore, this lady is delusional. Arguably delusions don't matter and aren't part of a disorder unless they are causing issues. In my opinion, capacity evals should only be done if there is a relatively immediate life threatening issue at stake. Otherwise, just let the person do whatever they want.

I agree with someone who posted earlier that in some capacity evals the fact that the patient is delusional is not necessarily important. So if the lady doesn't believe COVID exists but does acknowledge she has a serious lung infection and the other capacity criteria are met then why does it matter if she calls it "COVID" or "Joebidenitis" or "some random infection." The thing I'm not really sure of is how dumb or delusional the reasoning can be before they don't have capacity anymore. For example I think it's worthwhile to consider the difference between a person saying that antibiotics don't treat infection and a person saying they know antibiotics could help but they don't want them because it's against what God wants them to do.

Maybe this is my own ignorance, but I didn't think a person needed to have an identifiable mental illness to lack capacity? For example, I thought that if someone is refusing lifesaving treatment but is unable/unwilling to discuss why they are refusing or demonstrate any appreciation of benefits/risks of treatment vs nontreatment, even if there is NO evidence of mental illness, they still are not demonstrating capacity to make an important medical decision and it should be discussed by an ethics committee or if emergent the lifesaving measure should be implemented.

 

[Desired Member]

I don't know that I disagree with you, but unless there is a silent "...or medical illness..." you are sticking in there, this gets into some dangerous territory. If the incapacity does not stem from a psychiatric or medical illness, why pray tell should physicians have anything to say about it? What exactly is it that would qualify a physician to make a judgement about the reasons someone does something when they are not in fact linked to a clinical dysfunction of some kind? What would give them more of a right to do this than, say, an attorney or a priest or a telemarketer?

EDIT: if the answer is simply, "the law", okay, but the substantive question still remains.

I think because physicians are tasked with saving lives and are experts in medicine and telemarketers, priests, and attorneys aren't. These other professionals probably have little/no knowledge of the life saving intervention that the person is refusing and the nuances to the decision, and they aren't going to be around in these situations either. If a patient is refusing treatment in a potentially life threatening scenario, the patient needs to clearly say "no," provide some reasoning behind saying no (even a cursory answer, like 'I'm tired of medical treatments') . The patient needs to be informed of the risks of making that decision (e.g. 'if you don't do dialysis now, you'll probably go home and die from a heart attack within a couple days') and then the patient needs to acknowledge these risks ("I know I will die without this procedure but I just don't want to have a needle in my arm. I don't care if it may only be a one time thing and I may not need dialysis forever.") This is a kind of simplistic scenario but hopefully you get my drift

 

[Desired Member]

And if they say they can't die because God will protect them, and appear to mean it?

How about Christian Scientists? They might very well reject the premise that disease is even real and contend that it is all a spiritual malady mostly requiring more prayer, which they can do very well at home, thank you.

How about the "candida overgrowth" people who will insist their breathing problems are an excess of candida and that all they need now is to change their diet to eat less bread and maybe take an IV antifungal?




'Rational' and 'understandable' are doing a lot of heavy lifting here.



'I'm never going on insulin for my diabetes because my uncle went on the insulin and lost his eye and leg.' The patient does not engage further on this point and resists all attempts at education. Do they have capacity to refuse insulin?

Refusing emergent C-sections because of an unshakeable belief in the utter safety of 'natural' births and the conviction that surgeons are evil butchers who delight in mutilating defenseless women for no reason. That's a slight exaggeration, but I have met people for whom it would not be much of one.




So why shouldn't we be giving patients spiritual and financial advice? After all, surely we can understand the complexities of investing to a much greater extent than a functionally illiterate person who struggled to get a GED. Think of all the harm that results from their incomprehensible decision to go all in on a pyramid scheme. They clearly have no comprehension of the implications of this and how they are guaranteed to lose their shirts, even though we keep telling them. Better that we should take their credit card away from them, surely.



I don't know, who do you think is best equipped to analyze arguments or determine what decisions are and are not rational? Philosophers? Semanticists? Lawyers? Theologians? Rhetoricians? Logicians? Laconic and mysterious cowboys?

I had a capacity eval similar to one you listed. Without going into too much detail because #hipaa, the patient did not believe in death.
However, we ended up saying patient had capacity because patient acknowledged that without the procedure it would likely only be a matter of days before their body was buried in the ground and their family would be mourning them and not seeing them on Earth again.

 

[Mass Effect]

Tbh, I don't think this really matters in most cases of capacity and matters minimally here. My questions would be: Does she understand she's sick for whatever reason? If no, does she understand that she can be very wrong, and that the risks of being wrong are something she is able to verbalize and willing to accept? If she does, she likely has capacity, but obviously there are nuances to every situation. What matters isn't really her beliefs, it's whether or not she is capable of understanding that specific situation, the possible outcomes, and whether it's possible they can apply to her if her belief is wrong. In this case, it sounds like she's been through the pna rodeo enough times to know the general points, it's just a matter of if she can appreciate and accept the risks if her beliefs are wrong.

Have to push back a little here. The reason this case is so complicated and why there are so many varying opinions is because based on past behavior, her actions on this admission are different and are directly related to her false belief. So if this were her baseline, I'd agree that her past belief wouldn't matter. But that belief is what's driving her to act differently on this admission than prior admissions and it's what's making her want to leave AMA. So I think it's worth teasing apart whether this belief is what we'd consider a mental illness or if it falls in the category of an extreme overvalued belief because without this belief, she'd stay in the hospital.

 

[Desired Member]

Refusal to accept a fact is NOT the same as the inability to accept a fact. I've had this exact situation occur where a patient refused to believe they had a kidney injury (refused to believe the labs were accurate) but was able to state that if he did have an AKI that it could be potentially dangerous. He was willing to accept that risk but did not actually believe it was there.

I'm confused...he thought doctors fabricated his lab results?? And they determined he had capacity??

 

[Mass Effect]

What about personality disorders/traits? I had a patient who was displaying NPD traits who thought the doctors wanted to keep him to make more money and thought that he was sick but would ultimately be fine if he went home. He did not otherwise have any depression, anxiety, psychosis, etc. I realize you can't answer specifically but wondering what your general thoughts are on personality disorders and capacity evals

Thinking badly of doctors or their motives doesn't mean he didn't have capacity. The patient wasn't delusional as he knew he was sick but disagreed with prognosis.

 

[Desired Member]

Thinking badly of doctors or their motives doesn't mean he didn't have capacity. The patient wasn't delusional as he knew he was sick but disagreed with prognosis.

This is an interesting take. The doctors told him that he probably wouldn't survive if he left the hospital AMA. Patient thought he would. One could argue that he doesn't have am adequate grasp of the severity of his medical condition.

 

[clausewitz2]

I think because physicians are tasked with saving lives and are experts in medicine and telemarketers, priests, and attorneys aren't. These other professionals probably have little/no knowledge of the life saving intervention that the person is refusing and the nuances to the decision, and they aren't going to be around in these situations either. If a patient is refusing treatment in a potentially life threatening scenario, the patient needs to clearly say "no," provide some reasoning behind saying no (even a cursory answer, like 'I'm tired of medical treatments') . The patient needs to be informed of the risks of making that decision (e.g. 'if you don't do dialysis now, you'll probably go home and die from a heart attack within a couple days') and then the patient needs to acknowledge these risks ("I know I will die without this procedure but I just don't want to have a needle in my arm. I don't care if it may only be a one time thing and I may not need dialysis forever.") This is a kind of simplistic scenario but hopefully you get my drift

I get what you're saying, but my point was that once the sticking point becomes whether or not someone's process of reasoning is sufficiently impaired as to represent a departure from rationality, if the underlying cause of this departure is not related to any kind of health condition, it is still not at all clear to me why physicians can claim a special expertise.

I hear what y'all are saying about physicians having the medical knowledge, but if we are going to say it is possible to give a layperson adequate enough information about risks and benefits to be permitted to make a meaningful decision, it has to be possible to give a third party enough factual information to be equipped to make the determination of rationality.