Assessing Patients’ Capacity to Refuse Medical Care

Few people dispute the assertion that in a free society we all have the right to make our own mistakes—including our right as patients to refuse care we do not want. Indeed, this concept of informed refusal is well established in both the medical and behavioral health literature as well as in the law.

The answer to the question of how much understanding a patient must exhibit to be considered “informed” is less clear, however. For behavioral health patients who have concomitant, serious medical illness, the answer is often especially murky.

As Jeffrey P. Spike, PhD, and I recently discussed in an article in The Primary Care Companion, our experience is that psychiatrists and adult medicine physicians often assess patient capacity regarding the refusal of care in very different ways.

The 3 cases we presented in our article highlighted the tendency of psychiatrists to give patients the freedom to refuse care even if they do not express a full understanding of the details of their illness—provided that they do exhibit a basic understanding and have plans for meeting basic needs.

Adult medicine physicians, on the other hand, are inclined to require patients to state a more complete understanding of their illness and the consequences of refusing care, especially when that refusal might result in a serious, adverse medical outcome.

We believe this difference in assessing capacity is a reflection of psychiatric and adult medicine physicians’ different experiences of the health care world. Because psychiatrists frequently interact with the legal system in competency hearings, because most behavioral illness is chronic and fluctuates over time, and because the physiologic consequences of psychiatric illness are rarely irreversible (beyond acute suicidal or homicidal behavior), psychiatrists are generally reluctant to remove decision-making power from patients. While the process of psychiatric consultation often facilitates patients’ ability to understand their illness in a general way—especially regarding social consequences—asking psychiatrists to specifically evaluate medical illness decision-making capacity is often frustrating, as their frame of reference is the mental health system and the courts.

In contrast, because adult medicine physicians face acute medical problems that do not fluctuate but frequently deteriorate without treatment, they are generally reluctant to allow patients to suffer the ill effects of what they perceive to be harmful, irreversible medical decisions. While adult medicine physicians are taught to beware of paternalism, asking them to respect psychiatric patients’ self-determination is often frustrating, as their frame of reference is the intensive care unit and the morgue.

When a strong difference of professional opinion occurs among the clinicians caring for a psychiatric patient with serious medical illness, we recommend two interventions. First, we encourage engaging both the patient’s primary medical care clinician and primary behavioral clinician for input; hopefully, they have relationships and history with the patient and can provide context to help resolve these situations. Second, we strongly encourage obtaining formal ethics consultation, integrating both the psychiatric and hospital medicine approaches to assessing capacity—which we outline in our article—in order to find an empathic and pragmatic solution to these cases of refusal of care.

Financial disclosure:Dr Tunzi had no relevant personal financial relationships to report.