BTK_PC.E6_Journal Review in Surgical Palliative Care - Assessing Decision-Making Capacity_Recording

Hello and welcome back from the University of Washington's surgical palliative care team. I'm Ally Harta, joined by Dr. Katie O'Connell, Dr. Lindsey Dickerson and Dr. Virginia Wang. This will be our final episode for now, at least with Behind the Knife. We wanna sincerely thank Behind the knife for this incredible platform to discuss important and valuable topics in surgical palliative care.

And thank you so much to everyone who's listened to our episodes. I agree. It's been a pleasure to share our perspective and it's encouraging to know that the surgical community is embracing the inclusion of palliative care principles in surgical training and practice. As always, please feel free to reach out with any comments or questions about our episodes.

All right, team. Shall we get started? Let's do it. So for today's episode, we'll be focusing on the assessment of patient's medical decision making capacity. We found that the question of which providers should be assessing decision making capacity and

how they should conduct that assessment comes up quite frequently in surgery.

For today's episode, we'll be doing part journal review, part standardized patient scenario for simulated practice. To start, let's review the well-known and loved 2007 New England Journal of Medicine article by Dr. Paul Applebaum, titled Assessment of Patients' Competence to Consent to Treatment. A link to this article will be in the show notes.

Now, Virginia, I know what you're thinking and what's that you are thinking? I probably just confused our listeners because our episode is about medical decision making capacity. The seminal articles title uses the word competence. Can you help clear that up for us by defining capacity and competence to start?

Absolutely. So in simple terms, capacity is a clinical determination made by a healthcare provider and is decision specific. A person can demonstrate capacity to make one medical decision at a single point in time, but not another. Competence is a legal determination made by a court of law that is not specific to a single decision.

Great. Thank you for humoring me with that Virginia and clearing that up for us. Dr. Applebaum actually addresses this terminology directly in the second paragraph of the article stating that he uses the terms interchangeably since the quote distinctions between them are not consistently reflected in either legal or medical usage.

For the purposes of this podcast, we'll stick to using the term capacity, which is also how we tend to practice here at our institution. Okay. Now that we've touched on the what of capacity assessment, let's review the who, when, and why. Dr. Harta, can you start us off? Sure. Let's start with why medical decision making capacity matters as healthcare providers.

We all intuitively understand this, but it's helpful to specifically name it. As Dr. Applebaum's article states valid informed consent is premised on the disclosure of appropriate information to a competent patient who is permitted to make a voluntary choice. So determining either

implicitly or explicitly that a patient has capacity is a requisite for an ethically and legally valid consent for treatment.

If a patient doesn't have decision making capacity, a valid consent can only be obtained from a surrogate decision maker. There are ethical principles at play in a capacity assessment with autonomy on one side and beneficence and non maleficence on the other. So that's an excellent point, Dr. Harita, and I'm glad you named the fact that capacity assessments can be implicit or explicit as the vast majority of capacity assessments we do as surgeons are implicit.

The article touched on that specifically as well with Dr. Applebaum writing. In the absence of a reason to question a patient's decision making, the presumption of competence will prevail. So then what we'll discuss today can serve as the foundation of our implicit capacity assessments that we do as surgeons and providers, but is only formally used in documented in specific instances.

So Virginia, can you

talk with us about the who, which patients should have explicit capacity assessments? Patients with a diagnosis or history of dementia, stroke, psychiatric disorders, cognitive impairment, or traumatic brain injury are at higher risk for incapacity. Patients who are in the hospital with a delirium sedation who are on life sustaining treatments are also at risk for incapacity.

The socially isolated, older adult, meaning someone who does not have a surrogate decision maker in place, may also need a capacity assessment performed alongside a goals of care discussion in terms of when a capacity assessment should be performed, the criteria may seem self-explanatory, but are worth stating out loud when the patient is most participatory in the conversation or is thinking most clearly after all relevant information has been disclosed and after the patient has been able to process this information.

Great. Thanks for laying that out for us, Virginia. Dr. O'Connell, I'll ask you this one since you've emphasized this during our resident education, who should be doing capacity assessments?

So I did not learn anything about determining medical decision making capacity, and surgical training as residents.

We consulted psychiatry for capacity assessments without much consideration at all. And I was really surprised to learn in Palliative Care Fellowship that this was within my scope of practice as a physician all along, while I perform my own capacity assessments now, always using the Applebaum guideline, I highly recommend consulting, psychiatry for patients with known or suspected psychiatric illness.

And if you're present during the psych evaluation, they often show up to the bedside with a copy of the apple bomb table on their clipboard. That's a great reminder, Dr. O'Connell, and it's, it's why we're doing this episode. This is a skill that surgeons and trainees can and should have in their repertoire, and then we can get other teams involved in more complex cases.

So let's talk about the four criteria for determining capacity laid out in the apple bomb guidelines,

which involves assessing the patient's ability to demonstrate that one, they understand the relevant information. Two, they appreciate the situation and its consequences. Three, they can communicate a choice, and four, they can reason about the treatment options.

So understand, appreciate, communicate, and reason. So I'll go through each of these in order and the team can give examples. First assess understanding. This necessitates that the patient grasps the fundamental meaning of the information that's being communicated. This could include the nature of their condition, the nature and purpose of the proposed treatment risks and benefits and alternative approaches.

Virginia, what's an example of question or questions one could use to assess a patient's understanding of their situation? Well, you could say something like, can you tell me in your own words what your doctors have told you is going on with your health, or what are the risks and benefits of this specific treatment or not undergoing treatment for surgeons, we are usually

discussing operative versus non-operative treatment options.

That's great. Yeah. And in that, those cases you would kind of fill in the blank of whatever specific treatment you're offering. The next step then is assessing appreciation. And this requires that the patient acknowledges the medical condition and the consequences of undergoing or declining treatment, which we also call insight.

So Dr. Herda, how might you assess a patient's appreciation of or insight into their situation? I'll often say something like. What do you think this treatment is gonna do for you? Or why do you think we've recommended this treatment? The goal of the first step understanding is to ask patients to paraphrase what they've been told by their medical team.

And the aim of assessing appreciation is to determine if patients believe what their providers have told them. Patients can be in denial or disbelief, so even if they can repeat what their care teams told them, they may not truly have decisional capacity if they don't demonstrate insight into their potential repercussions of the management options.

Thank you for making that distinction clear, Dr. So after a patient demonstrates they understand and appreciate the situation. The final two criteria to determine capacity are that the patient communicates a choice and describes their reasoning for why they're making this choice. This can be two separate steps, but they're often combined into one, depending on how the patient answers and how the conversation flows.

So Dr. O'Connell, this seems to me to be the crux of evaluating decision making capacity. Can you share with us how you do this? So the assessment of a patient's ability to indicate their preferred treatment option can be as simple as how would you like to proceed, or given what we've discussed, can you share the treatment option you've selected?

This could be a difficult choice for the patient. So if they haven't made a decision, you might ask, what is making this hard for you to decide in Virginia? I'll throw a question over to you. What is one critical element of

communicating a choice that could influence whether you determine a patient to have capacity?

In my experience, the patient should communicate the same choice consistently. Intermittent reversal of choice should prompt you to investigate further patient's. Indecision does not always mean that a patient does not have capacity. Sometimes patients, just like the rest of us, need time to weigh their options when making difficult, life-changing decisions.

When I'm having these conversations, I try to make it very clear to patients that big or complex decisions can be very difficult to make, and many people need time to process their thoughts after having received a large amount of information at once, and I don't know yet is a perfectly reasonable answer, but there are times when a sweeping reversal of choice, after it's been clearly stated, can be an indicator that a patient may not have capacity.

This doesn't necessarily mean that you're obligated to ask the patient several times to state their preferred treatment when assessing decision making capacity, but if you notice the patient has reversed their choice either during one

conversation or across multiple conversations with one or several providers, and does not provide a coherent reason or thought process for this, that should clue you into a potential concern.

Yeah, that's right. The cases in which patients are not accepting our recommended surgical treatment. Especially when there's a threat to longevity pose the most discomfort for the team. In these situations when there is consistency for the decision documented in the chart or elsewhere, such as advanced care planning documents, this adds value to your assessment.

So for example, you have a cirrhotic patient with a large umbilical hernia. Who has refused elective surgical repair consistently over the years, who presents to the emergency room with a ruptured umbilical hernia and continues to refuse surgery. During your chart review, you find multiple encounters where the patient has elected to forego umbilical hernia repair.

Despite understanding the risks of medical management alone, this history is valuable data to include in the capacity assessment. And as Lindsay said, patients must be able to provide rationale for the treatment choice they make. For this part, you could ask something like, you know, tell me about how you came to this decision, or, or how are you thinking about surgery?

What led you to decide not to have surgery? This is a really critical part of assessing capacity and, and so I wanna take a moment to emphasize something as providers assessing capacity. We don't need to agree that the decision the patient is making is reasonable. They're permitted to make choices that go against our medical advice or have values that are different from ours.

And for a patient to have capacity, they only need to demonstrate that they were thoughtful and logical in their choice. I'm really glad you brought that up, Dr. Carta. It certainly can be difficult at, at times not to let our own opinions influence how we talk with patients or interpret their understanding and

preferences.

Other thoughts on that? I wanna say something a little bit about being aware of our own biases when we walk into a room to have these conversations with patients who have diagnoses like schizophrenia or dementia or cognitive impairment or with elderly patients. Sometimes I think it is difficult as a provider not to walk into those encounters with a preformed notion of whether the patient will or won't have capacity to make a medical decision, and I think it's important.

To be conscious of those biases and try to mitigate them as a physician performing a capacity assessment and not letting that bias or prejudice color your assessment in the moment. It seems like maybe a very basic thing to do, but I do think some of the work in surgical palliative care is carrying a certain kind of cognitive load in that way.

Thanks for bringing that up, Virginia. I think that's a really important point, and it's always important to talk about the biases that we bring into our care and conversations. All right, so to wrap up our article review before moving on to the

simulated patient scenario, there are a few additional considerations that we haven't touched on yet.

Dr. Herda, any final discussion points that you have pulled out from the article? Yeah. I think one critical point to remember is that we should try to correct any identifiable factors that are affecting cognition prior to a capacity assessment. I think delirium is especially worth mentioning here as an example.

By definition, delirium is fluctuating disturbance of consciousness and cognition, right? It waxes and wanes, and it's often reversible. So if a patient is delirious, there might need to be coordination of the capacity assessment with the bedside nurse who's performing delirium assessments to optimize the timing of the assessment.

And also remember that just because a patient lacks capacity in that moment when they're delirious, does not mean that as they clear throughout the hospitalization, they will always lack capacity. Right. So then if after one or multiple capacity assessments, and after correcting any identifiable factors that affect cognition, you determine that a patient does not have

medical decision making capacity.

Where do we go from there? Without medical decision making capacity, we turn to the surrogate decision maker to help guide decision making for the patient. If there is no surrogate, and the patient lacks medical decision making capacity in emergency situations, physicians can legally and ethically provide treatment under the presumption that a reasonable person would have consented to the treatment.

In cases where surgery is recommended to preserve longevity, and the patient refuses surgery and lacks capacity, it is very appropriate to load the boat. Consult, psychiatry for a second capacity assessment and involve the anesthesia team in the decision making process. Documentation of the capacity assessments and the multidisciplinary decision making must be completed.

Thanks, team. That was a great discussion of such an important article. That means it's now time for everyone's favorite exercise, a simulated scenario.

Virginia will be the surgeon performing the capacity assessment and Mr. Fuller is the patient. Mr. Fuller is a 58-year-old with a past medical history of poorly controlled type two diabetes, peripheral vascular disease, CKD stage three, hypertension and depression, not currently on medications who presents with right foot gangrene on examination.

His foot is cold and cyanotic with tissue necrosis and foul smelling drainage. His workup is notable for leukocytosis, elevated lactate, and signs of sepsis, including mild hypotension and tachycardia. The surgical team recommends a below knee amputation as a life-saving measure and explains that without a, B, K, A, Mr.

Fuller is at risk for overwhelming sepsis, multi-organ failure and death. Fuller, however, refuses surgery saying I'd rather die than lose my leg, and I don't want to be a burden to my family. His daughter is present and pleads with him to reconsider insisting that he isn't thinking straight. Due to his worsening infection and history of depression,

the anesthesiologist has met with Mr.

Fuller and they're concerned about doing the surgery because he has refused the amputation during a previous admission. Okay. Let's jump into our scenario where Virginia is meeting Mr. Fuller. Hi, Mr. Fuller. I'm Dr. Wang. I'm one of the residents with the general surgery team. Hi doc. How's it going? Good. I wanted to talk to you about the decision making about your amputation.

Can you tell me a little bit about what the doctors have told you so far about what's going on with your foot? Yeah. And they basically told me I'm dragging around dead weight now. Literally there's an infection and that's making it so I'm getting pretty sick. I mean, I don't know. I, I've had this issue before and so now I got a doctor telling me he wants to chop my foot off or else I'm gonna die.

Can you tell me a little bit about what you think about all of that? What do you think will happen to you without the amputation? Well, guess my crystal balls on the

fritz. I don't know what's gonna happen. They're talking about hooking me up to some machines for my kidneys. Because there's problems there and possibly even breathing.

I, I don't know. They're, they're saying a. That's right. So you are very sick from your infected foot, and I'm worried that without the amputation, the infection will take over your body and your organs will shut down despite our best efforts to support them with machines. I know you've decided before not to have an amputation of your foot.

Can you tell me a little bit about how you're thinking about medical treatment versus surgical treatment of the infection this time? Well, yeah, I. I had an uncle years ago, he had his leg amputated and he was just miserable for, for years. He was in pain all day, every day he had to use a wheelchair and it just, I mean, his whole life

just fell apart.

We all had to watch this. He ended up in a nursing home and I not, I'm not doing that. I'm just not. I had to watch him go through all that and I'm not gonna follow. That I just can't, and I know my daughter wants me to get this surgery, but she's the only one that can do anything if I'm gonna need extra help and, you know, I'm not gonna do that to her and I'm not gonna go to a nursing home.

I'm not. Okay. I can see that you love your daughter very much and you really care about her. Yeah. I mean, there's, it's just, it's. It's just me and her, and she has got her hands full with with her family, with her kids, and I don't want to be a burden putting all of my crap into her life. I hear you. So just so we're on the same page, my recommendation to you is a bologna amputation of your infected foot as a lifesaving measure, there are alternative treatment plans, so one of those would be

antibiotics and organ support, whatever form that may take.

Another alternative could be of comfort, focus, treatment plan, which would not involve some of those measures, including the organ support. Could you tell me what your thinking is surrounding that decision? Well, I mean, from the things you're saying, I, sorry, you're gonna have to keep saw put away today.

Let's.

All right, so this scenario was an example of a patient who has medical decision making capacity and is not electing to follow our treatment recommendation. He was able to demonstrate understanding of the situation, appreciate the risks and benefits of the treatment options, demonstrate reasoning about the treatment options, and then communicate his final choice.

Now, Virginia, can you take it from the top and run this scenario again? Absolutely. Hi, Mr. Fuller.

I'm Dr. Wang. I'm one of the residents with the general surgery team. Sure. Could you tell me a little bit about what the doctors have told you so far about what's going on with your foot? I know I say all kinds of crap.

My foot's. My foot's dead. My foot's infected. What my foot is, but I, they're, they're trying to cut it off, and I'm not gonna let them do that. Okay. Well, we're very worried that your foot infection is making you sick and without treatment, without an amputation, it might make you so sick that you could die.

What do you think about all of that? Listen, I just don't think it's necessary. You know, I, if it's my time, it's my time. God will tell me. It's my. You know, I just wanna get out of this freaking hospital and go home. That's what I want. Okay. Well, we're really worried about you getting very, very sick at home, and we don't think it's safe for you to leave the hospital yet.

Can you share with me

what worries you about having surgery? Okay, well, you can't, I know my rights. You can't keep me here. Okay. So if you just let me go home, I'm just gonna go home. I've got things to do. So I, this is the last place I want to be. So what do I gotta do? Who do I gotta talk to to get outta here?

I understand that we don't keep people here unnecessarily, and we just want to understand what you think would happen when you go home. I don't know. I don't know what'll happen when I go home. I know I'll still have my leg. I know I'll still have my leg when I, if you let me go home. I mean, I don't understand the problem here.

I. I, I don't know what's gonna happen. I know that I'll be home where I wanna be. Alright, time out. So in contrast to the first scenario, Mr. Fuller lacks medical decision making capacity here, and he was able to demonstrate understanding to some degree, but with

repeated prompts, he was not able to demonstrate appreciation for the situation at all.

In these cases, it can be helpful to get a second opinion, which could be another surgeon, or if you are concerned about how his mental health might be contributing to his decisions. A psychiatry consult could be considered if you determine that the patient does not have capacity. This is when you would engage a surrogate decision maker.

Before we conclude, I want to introduce and thank our standardized patient, Mr. Mark Fox, who is a Seattle based actor. Mark, is there anything you would like to say for our behind the knife listeners? Just thank you. Thank you for listening. Thank you for being open to what's being offered here today and thank you for the work you do saving lives and I'm just happy to play some small part in it.

We appreciate your help so much. Well, with that, it's sadly time to wrap up our episode. Today we

reviewed the Apple Bond framework for assessing decision making capacity, using four criteria, understanding, appreciation, communication, and reasoning. I. We discuss that any physician can perform a capacity assessment and consulting.

Psychiatry can be very helpful and would be recommended for patients with known or suspected psychiatric illness. As with many aspects of surgery, capacity assessment is both a skill and a responsibility we can grow more comfortable with through practice. We hope today's discussion gives you more confidence to approach these conversations thoughtfully and effectively.

Thank you all for listening and from the surgical palliative care team at the University of Washington.