Informed Consent, Competency and Capacity

00:00 So that brings us to the idea of informed consent. Now, per Judge Cardoza in 1914, patients of adult age and sound mind have a right to refuse treatment. That’s very important to remember.

00:16 So therefore, when it comes to making treatment recommendations, we go through a process of informed consent with our patients. So we, first of all, assess their target symptoms, we offer recommendation and then we go through informed consent where we talk about the diagnosis, the risks and benefits of taking treatment and alternative courses of actions and remember a patient of sound mind has a right to refuse or accept. When it comes to making the best recommendation possible, you as a doctor want to look at a patient’s target symptoms. So, ask yourself “What are you treating here? What is the underlying disorder or symptom that the patient really wants to have addressed and that you think is in the top order of priority?” You're going to think about exploring the history of medications that the patient has tried in the past, what have they tried before, what kind of reactions do they have, did anyone in the family ever taken medication and if so why and what was their response?” You’re going to also consider the potential for lethality and side effects with various medications and explore those with your patient. You’re going to want to make sure you know about your patient’s allergies and also you’re going to be keeping in mind drug-to-drug interactions when you make your recommendation and also the side effect profile of medications. Patients must knowingly and voluntarily agree to any intervention, treatment, or procedure. When it comes to what a patient needs to know versus situations that may not require informed consent. This is an important nuance because the patient who is of sound mind and able to engage with you in a risk-benefit conversation is going to need to know a lot of information. In an emergency situation when somebody’s life is at risk, you may not be able to engage so much in an informed consent conversation because you’re acting to benefit your patient acutely. So here are a few of the criteria. Let’s go over what’s necessary for informed consent. So patients must have an opportunity to ask you questions.

02:29 They have to be able to have the capacity to make an informed decision. They need to be able to understand and you need to tell them the name and the purpose of the treatment, the consequences of both taking and refusing the treatment, the risks and benefits and also the alternatives.

02:45 Now, situations that don’t require informed consent include minors.

02:51 A quick note regarding emancipation: minors are emancipated if they’re self-supporting, in the military, married, or have children of their own.

03:03 Other situations that don’t require informed consent is when there is an emergency situation like somebody is at risk of harm to themselves or others. At this point, you may hospitalize them without going through a whole informed consent process about hospitalization because the patient may in fact be too agitated and dangerous on that moment to be able to really engage with you.

03:30 Also for a life-saving medical emergency, this is also an exception to informed consent where you may forego the discussion because in fact the patient may not be able to participate and you need to act very quickly or else they can have a terrible outcome. To reiterate, minors are emancipated if they’re self-supporting, in the military, married, or have children of their own.

03:55 That’s also an important point to know when it comes to informed consent. Now when it comes to competency and capacity, it’s important to know that competency is actually a legal term and can only be decided by a judge whereas capacity can fluctuate over time and it’s tasks specific. This is something that a doctor can make an opinion about and it’s assessed on a case by case or treatment-specific basis. Again, very important point “only a judge can determine if a person is incompetent, physicians can determine the capacity of a patient.” So in terms of assessing capacity, here are the important criteria. A patient must be able to communicate a clear and consistent choice. They must understand the relevant information including risks and benefits. They have to be able to logically manipulate and understand the information as well as alternative options and they have to be able to express a rationale for their choice that is rooted in reality. So a patient must meet all 4 of this criteria in order to be found to have capacity to make a decision. Consider a patient like Jane. "She communicates to her doctor that she actually has a preference to take medication but also she is adamant that she not take anything that will cause her significant weight gain. She understands her options including antidepressants and also has the understanding that a low-dose antipsychotic such as quetiapine might help to boost and stabilize her mood and alleviate her intermittent anxiety and suicidal thoughts. So, she asks if there are any other options for those symptoms because she is very fearful though of weight gain and she tells you that the rationale for her choice is that she has a history of severe back pain due to previous obesity and she'd really like to avoid further problems with either of those things." So, my question for you is “Does Jane have the capacity to make a decision about what medication she takes or refuses?” Well, think about it. She’s been clear and consistent in her choice. She does verbalize knowing the risks and benefits. She also asked about her treatment options and discussed in detail her target symptoms. She is trying to avoid further weight gain and back problems, which seems to be a very reasonable decision. So she really does meet all 4 criteria for the capacity assessment and therefore would retain her right to refuse and accept treatments with her doctor. So, Jane does have capacity. This concludes our talk about some of the civil issues in Forensic Psychiatry. Know a little bit about what it means to involuntarily admit a patient against their will, you know a little bit about the informed consent process as well as what it means to be competent versus having capacity.