Last Saturday, I had the pleasure of attending an interdisciplinary conference between first year law, medical, social work and physician assistant students. They examined and discussed this case:
http://www.npr.org/sections/health-shots/2015/01/08/375659085/can-connecticut-force-a-teenage-girl-to-undergo-chemotherapy
As it is every year, the discussion was very interesting. I was struck again about how quickly you can differentiate the law from the medical students - you can do it within a few seconds of hearing them speak. These are students in the first few weeks of their professional studies - and they already wear distinctive mantles. This conference (usually held on the first truly beautiful Saturday morning of fall - a tragic thing for all of us) always gives me a lot to think about. I try not to say too much during the goings on, but here's what I sent off to the students today on the subject of consent, capacity, and doing the right thing.
1.
Objective Criteria for Determining Maturity
– several people made mention of using some objective criteria to decide
whether a patient was mature enough to make medical decisions. Something like that would be useful, but
nothing like that exists. It’s hard to
define what we mean by “maturity.” Any
attempt to objectify it becomes arbitrary.
Part of the issue is that the ability to make a decision for one’s self
depends not on age or maturity so much as what the decision at hand actually
is. I may not trust a 5 year old to make
a decision about chemo, but I would let them decide what to eat for dessert,
for instance. But I wouldn’t let a baby
decide what to eat, because they might literally eat poison if it was brightly
colored. And so on.
Close to the maturity issue, I
think is the issue of Informed Consent.
FYI, you can break this down into a few specific questions. Does the patient have the ability to
understand the information they need to make the decision? (So they need to be able to listen/look/think
and also to communicate back by some method their understanding). Second, can they tell me the consequences of
their action? (for instance, “You (the
doctor) are worried that I will die of infection or sepsis in less than a week
if I do not take this antibiotic.”) If
the answers to these questions are yes, and you don’t think the patient is
being coerced by outside forces (a controlling family member, etc) – then the
patient has decisional capacity. As you
can see, if you are very young, you may not meet the first criteria, and if you
are delusional you might not be able to fit the second. However, it’s decision specific. A patient may have the ability to make some
decisions but not others.
If a patient has decisional
capacity, they get to make the decision, even if you think it’s a terrible
decision. That’s our right as autonomous
humans. BTW, law states that if
decisional capacity is in question, two doctors need to weigh in and come to
consensus on it. It doesn’t state that
it has to be two psychiatrists – although they are often asked to assess
capacity/competence (“capacity” is the more PC term) because it comes up not
infrequently in patients with significant mental illness. Any licensed physician can assess decisional
capacity.
2.
Protecting Patients from their own Regrettable
Decisions. I saw a trend for the law
and medical students to come down on different sides on this. Apart from the question of letting patients
make bad decisions is the issue of how hard we should try to convince them to
decide otherwise. This process is part
of that mysterious “art of medicine” that you hear doctors talk about. You’ll never read about how to do it or where
the line is in doing it in a book. You
will deal with the impulse to do this with almost every patient. So, here are my two cents.
Your ideas on this will change as
you practice. When I was a
student/resident/new practitioner I tried very, very hard to get people to make
what I thought was the best decision. I
think just about everyone who saw me doing this would have given me an A for
effort. The problem was that even though
my effort was massive, the results were anemic.
The truth is, as a doctor, you can lean and lean and lean on someone
until you force them to say “ok, I’ll do it your way.” And they may actually do it your way for a
while. But then they’ll get out from
under your thumb at some point, and guess what happens then? They do what they want. AND they no longer will come back to see you
– because you and they, they have correctly surmised, do not see eye to
eye.
People need time to figure things
out for themselves. Sometimes they have
to see things for themselves. Educating
someone about their problem sometimes takes many visits over long periods of
time. Sometimes they need time to talk to other people and let things sink in,
etc. etc. There are very few times in
medicine where people must follow your advice immediately. So when people choose a course that I think
is a mistake, I let them know that they should keep checking in with me to see
how they are doing and then, if I think they have decisional capacity, I let
them do what they want. I have learned a
lot about medicine this way, because many times something I thought was a
terrible decision turned out to be a good one for the patient in the end.
3.
No
fighting. If I can tell you nothing
else, it’s that if you are fighting and arguing with a patient, you are doing
it wrong. I think if you really can’t
disengage and in good faith live with a decision your patient is making, you
should recuse yourself from the care of that patient. I would tell you though, that when patients
realize you’re still on their side even though you don’t love what they are
doing, they really appreciate it.
Knowing that you support them without judging the way they are running
their life often opens the door to them listening to you and trusting you
more. It’s through this kindness that
patients will sometimes change their minds and consider doing something much
better for themselves!
