Of Capacity and Communication

I am about 45 minutes from the end of my night float shift, that dangerous hour all residents learn to wait through with baited breath, when my pager goes off. Pushing the button to silent its insistent beep, I read the text: “STAT 4-9876.” I am slightly bemused. STAT pages in psychiatry are few and far between. If one of the patients on the psych floor has had an MI, stroke, or something else that necessitates an immediate response, I may be the last to find out, as the nurse will often call a code and bring a medicine team running before letting me know what is going on. Even a consult for a suicidal patient on a medicine floor, considered a psychiatric emergency, doesn’t exactly necessitate the same sort of urgency as anaphylaxis or an acute abdomen. I like pondering and deliberation, making me naturally suited for psychiatry. Rather than engendering excitement, the word STAT makes my blood run a little cold. Besides, I typically assume that if someone is paging me, urgency is implied, and I return the call immediately; the two year old inside me smarts at being told to hurry up.

“Hi, this is Megan returning a page.”
“This is Sam with gen surg*. We have a situation and need you to come now.” The other end of the line buzzes with tension as the story comes out in staccato bursts. The patient is a woman in her 20s, admitted for injuries that resulted after she got into an intense argument with her husband and leapt from their moving car. To add to that, she is pregnant. Quickly scanning her chart as the resident talks, I see the psychiatry consult service has already seen the patient the day prior, deciding she may have been rash and impulsive, but is not actively suicidal. “We have her scheduled for surgery this morning and she’s refusing,” Sam concludes. “We need you to decide if she has capacity.”Capacity refers to a patient’s ability to make an informed decision. While competency is a legal question decided in court, capacity can be determined by any physician and refers to a specific medical situation rather than a global ability to decide about one’s own care. Capacity is a funny thing. If the patient is agreeing with our medical advice, we are inclined to believe she has capacity unless something is glaringly off with her mental status. Turn down our medical advice and capacity can come into question for the sanest-seeming of patients.
Capacity involves four key components. First, the patient must understand the procedure or treatment to be performed. What are the options? What are the risks and benefits of the proposed procedure? Second, the patient needs to understand how this procedure or treatment relates to her specific situation. Does she understand her current medical condition? Does she understand what will happen if she agrees to the treatment? Next, the patient needs to use reason to make her decision. Can she explain why she has made this decision? Finally, the patient must be able to consistently communicate her choice.
While all physicians can determine capacity, the question often falls to psychiatry, particularly when the consequences are serious. Here, the woman could have significant long-term disability without surgical correction of her fracture. But to do surgery on someone against her wishes? Not something to be taken lightly.
I take the stairs two at a time, reaching the patient’s room just as the surgery team is leaving. The patient is lying in bed, one leg stabilized and set up on pillows. Between the patient’s tears and the team’s frustration, the anxiety in the room is palpable. “Thanks for coming,” the resident says, “let me know how it goes.” I nod.
With a certain amount of trepidation given the task at hand, I approach the patient’s bed. “Hi, Mrs. K. I’m Dr. Riddle, one of the psychiatrists here. I was hoping you’d be willing to chat with me.” A beat later though, I realize the conversation will have to wait a minute. Mrs. K speaks only a handful of English. As I excuse myself to search for a translator phone, the nurse remarks, “She seems to understand pretty well.”  Not well enough for this conversation, I think to myself.
With the benefit of an interpreter, we start our discussion. My goal is to understand rather than interrogate. When I say I heard she does not want the surgery, she looks at me with surprise.  No, that’s not true. I do want the surgery. And with the translator phone, the other side of the story comes out. Overnight, she says, no one has explained to her what is going on, assuming she has understood their English better than she does. She is afraid of the effect of the surgery on her unborn child.  Is it safe for my baby? she asks, one hand placed protectively on her belly. In addition, she has been moved to a new room where she feels no one is keeping watch over her and, were something to happen following the procedure, she fears no one will be there to respond. (I learn later that she had been transferred out of the ICU, with its intensive monitoring and constant nursing presence on an open floor, and into a private room; rather than seeing this as an improvement and an indication of her stability, she feels she is being ignored).
I promise to speak with her nurses and the surgery team, reassure her that she will be carefully monitored. Her face visibly relaxes. I pass along to the team the patient’s confusion, and what I have tried to clarify. The surgery team is appreciative and the patient goes to surgery later that day without complications.
What was supposed to be a consult about capacity has become one about communication. Although may sound like an extreme case and it’s tempting to stereotype the other team, we’ve all almost certainly done something similar to some degree or another. It can be easy, with the press of time and break neck speed of the hospital, where our to-do lists never seem to be all checked off, to assume the patient understands what is going on, that we have explained things well. And we may have explained things well, but is it well enough? Barriers in communication can be as basic as language, but even for native speakers, meaning can get lost across differences in education, upbringing, and cultural mores. Regardless of specialty, part of training to be a physician means learning how to bridge those divides. Although never perfected, it is a skill that we must continue to work on throughout our careers. We owe that to our patients.
*Please note: Names, specialties, and superficial details have been altered to protect privacy of those involved, HIPAA and otherwise.
Tunzi M (2001): Can the patient decide? Evaluating patient capacity in practice. American family physician. 64:299-306.

About the Ads
Megan Riddle, MD PhD, is a psychiatry resident at the University of Washington. She is a graduate of the Weill Cornell/Rockefeller/Sloan-Kettering Tri-Institutional MD-PhD Program. Megan Riddle, MD PhD, is a psychiatry resident at the University of Washington. She is a graduate of the Weill Cornell/Rockefeller/Sloan-Kettering Tri...