(PO-091) (PO-091) Decision-Making Capacity in a Patient with Frontal Anosodiaphoria in the setting of Invasive Basal Cell Carcinoma

Background
Assessment of patients’ medical decision making capacity (DMC) accounts for as much as 25% of all requests for psychiatric consultation in the hospital setting(1). The Appelbaum and Grisso criteria are the gold standard, but reflect a distinctly cognitive approach to the assessment of DMC, where a judgment of incapacity is conditional upon a failure to manipulate the facts of the medical situation and where emotional appraisal is largely irrelevant. Anosodiaphoria, or a grossly abnormal indifference to one’s illness, has not been adequately explored as an obstacle to capacity assessment.

Case
A 71 year-old man presented to inpatient care with a 30-year history of a progressively enlarging facial skin lesion for which he delayed diagnosis despite extensive invasion into his orbit and nasal bridge. On biopsy one year prior to presentation, he was found to have basal cell carcinoma with invasion into the cranial vault, and was now admitted for associated dural breakdown and cerebral abscess. Psychiatry was consulted for capacity assessment when the patient declined surgical intervention for infection control. On assessment, he was found to satisfy the criteria for decision-making capacity, but was noted to be incongruently jovial and unconcerned with his clinical state, consistent with frontal lobe syndrome due to right frontal intracerebral abscess and vasogenic edema. Despite evidence of anosodiaphoria, the patient retained capacity and was discharged without surgery. He returned one month later with worsening cerebral edema with subfalcine herniation, and was deemed no longer a surgical candidate.

Discussion
Current decision-making capacity criteria focus on cognitive aspects of decision-making rather than emotional aspects. Patients with frontal anosodiaphoria may lack DMC even though they satisfy existing cognitive criteria for DMC.

Conclusion
Patients with anosodiaphoria may lack DMC due to deficits in emotional processing even though they satisfy the cognitive criteria. Emotion-based criteria should be included and operationalized in addition to cognitive criteria for DMC, consistent with contemporary neurobiological understanding of decision-making.



References:
(1)Appelbaum, P. S. (2007). Assessment of patients' competence to consent to treatment. New England Journal of Medicine, 357(18), 1834-1840.