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Psychosomatic medicine psychiatrists are frequently asked to determine whether or not patients who are psychiatrically, cognitively, or physically compromised may be discharged into settings in which it is foreseeable that they will “fail to thrive,” or might succumb. In contradistinction to consults for determination of capacity to accept or refuse specific treatments or procedures, which involves a “here and now,” evaluation of decision making ability based on the doctrine of informed consent, the evaluation of dispositional capacity requires a judgment about the likelihood that the patient can actually accomplish the tasks necessary to survive outside of the hospital setting, both “now and in the future.”
Dispositional capacity consultations are often called for “administrative” reasons on an emergency basis, for patients previously unknown to the psychiatrist and who are “at the door,” and who may need to be restrained and committed, if YOU say they cannot leave against medical advice. The demand for what is basically instant adjudication presents a combined clinical, ethical, moral, emotional, and medico-legal challenge to the psychosomatic medicine psychiatrist and the primary medical team. Although the question is often simply posed as “can the patient go?” the expectation is that the psychiatrist will assume responsibility (the burden) for “licensing” the discharge and “guaranteeing” the patient’s survival, at least in the short term.
We review the general outline of medical decision making, including the concept of “flexible capacity,” clarify the distinction between medical decision-making capacity and dispositional capacity, and introduce the construct of capacity for self-determination. The capacity for self-determination construct is comprised of a three dimensional model to determine dispositional capacity which combines with the evaluation of the patient’s decision-making ability (Cognition), a consideration of physical performance abilities (Praxis), and interpersonal efficacy (Agency) or the ability to influence others to provide the resources necessary for the patient’s wellbeing.
Presentations:
Decisional Capacity Determinations: From Informed Consent to Dispositional Capacity-James A. Bourgeois, OD, MD, University of California San Francisco, San Francisco, CA
Capacity for Self Determination-What Is It? – Henry R. Bleier, MD, MBA, University of Pennsylvania, Philadelphia, PA
Practical Aspects of Decisional Capacity Determinations – Mary Ann Cohen, MD, FAPM, Mount Sinai School of Medicine, New York, NY
In the Trenches – A Resident’s Perspective - Katharine B. Dalke, MD, MBE, University of Pennsylvania School of Medicine, Philadelphia, PA
The State of Legal Affairs”- What is Our Jeopardy? - John K. Northrop MD, PhD, University of Pennsylvania School of Medicine, Philadelphia, PA
Chair: Henry R. Bleier, MD, MBA, University of Pennsylvania, Philadelphia, PA
Discussants: James A. Bourgeois, OD, MD, University of California San Francisco, San Francisco, CA and Mary Ann Cohen, MD, FAPM, Mount Sinai School of Medicine, New York, NY
