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  1. Who determines the competency of an individual?

  2. How does a clinician determine whether a patient has decision-making capacity?

  3. What are the assumptions of informed consent or refusal?

  4. What are the questions a clinician should ask a patient who wants to leave against medical advice?

In the United States, a driver's license assumes competency to drive a car despite absence of proof that competency exists and despite statistics that as many as 50,000 Americans die and many more are disabled from car accidents annually. The same is true for obtaining a license to own a gun. When patients agree with recommendations of their physicians, the issue of competency is rarely raised despite the absence of competency. It is when patients and physicians disagree—when patients make decisions that clinicians feel are detrimental to their well being—that issues of competency are raised. The issue of competency is complex. Many medical decisions are affected by personal issues, religious and spiritual beliefs, or social pressures.

Competency is primarily a legal term rather than a medical one. Informed consent implies that patients have certain rights and expectations when it comes to making decisions regarding their own medical care. Patients have the right to be informed, their decision making should be voluntary, and they must be competent to make adequate decisions. In the hospital setting, the most common question posed to consultation liaison psychiatrists relates to decision-making capacity. Psychiatrists may help in the assessment of a patient's cognitive and emotional ability to make a decision. The hospital's ethics committee may help resolve the primary issue affecting the patient, especially if it is more a moral decision involving life and death decision making rather than a clinical one. The patient's spiritual advisor or hospital chaplain may be invaluable in sorting out the relevant issues and promoting resolution of conflict when decisions are made that make the medical providers uncomfortable (Figure 227-1).

Figure 227-1

Algorithm for the patient who refuses recommended treatment.

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Case 227-1

MECHANICAL VENTILATION

Three weeks ago a 68-year-old woman sustained a cervical spinal cord injury from a fall. Quadriplegic, she will likely die if artificial ventilation is discontinued. The patient stated that “my life as it is now is not worth living. I am not happy.” The patient seems to understand the implications of discontinuing artificial ventilation. The patient's family wants her to continue mechanical ventilation and they are concerned about the patient's thought process. Is this patient competent to make such a decision?

Is this patient competent to make medical decisions relating to her care?

This patient wants to discontinue mechanical ventilation. Does this patient truly understand the choice she is making? Is this patient depressed? Could this patient's mental state impact her decision to stop mechanical ventilation? Does this patient have the ...

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