(PO-047) (PO-047) Systematic Assessment of Decisional Capacity in Communication-Impaired Patients With Severe Psychiatric Symptoms

Background: Severe psychiatric symptoms, such as suicidality or psychosis, can impair insight and judgment. Careful evaluation is often needed to ensure decision making capacity is not compromised, especially in end-of-life decisions. These evaluations can be challenging and are further complicated by limitations in communication. We present a case in which capacity to make end of life decisions was evaluated in a non-verbal patient with suicidality and psychosis and offer a systematic approach to such evaluations.



Case: A 41-year-old man with schizophrenia and polysubstance use presented after a suicide attempt which resulted in C7-T2 fractures rendering him functionally quadriplegic. Surgical course left him alert but intubated and non-verbal. He intermittently refused urgent blood transfusions, requested withdrawal of life-supporting care, and declined to allow his next-of-kin to serve as surrogate decision-maker. Psychiatry was consulted to evaluate his capacity to make these medical decisions. The patient’s cognition, psychosis, mood, suicidal ideation, and understanding of his clinical condition and the recommended medical interventions were systematically assessed through a series of yes/no questions. On evaluation, he demonstrated adequate orientation, understanding, and comprehension; however, his reliability was questionable at times and his short-term recall was impaired. He was experiencing profound symptoms of psychosis including auditory hallucinations telling him to hurt himself and paranoia about his next-of-kin’s intentions. Therefore, we determined that the patient did not demonstrate capacity to consent to withdrawal of life-sustaining treatment or to choose his surrogate decision-maker. He could, however, assent to other interventions which he now wanted (e.g., transfusions and psychotropic medications).



Discussion: To the authors’ knowledge, this is the first report regarding decision making capacity to withdraw life-sustaining treatment after a near-lethal suicide attempt in a non-verbal patient with psychosis. Given that 26.8% of patients with schizophrenia attempt suicide and the likelihood that severe bodily injury could render a patient non-verbal with adequate cognition, it is likely that consultation-liaison psychiatrists will encounter similar situations (Lu 2020). However, there are no recommendations on conducting such capacity assessments. Building upon communication strategies in patients with Locked-In Syndrome (Maiser 2016), we will present a suggested organizational framework to ensure comprehensive and reliable assessment of decision-making capacity in these situations.



Conclusion: Non-verbal patients with severe psychiatric symptoms present unique challenges in the evaluation of decisional capacity. A structured and methodical approach to these evaluations is necessary to both maximize accuracy of determinations and ensure protection of patient autonomy.



References:

Lu, L., et al. (2019). Prevalence of suicide attempts in individuals with schizophrenia: a meta-analysis of observational studies. Epidemiology and psychiatric sciences, 29, e39.



Maiser, S., et al. (2016). Locked-In Syndrome: Case Report and Discussion of Decisional Capacity. Journal of pain and symptom management, 51(4), 789–793.