From whom can consent be taken for a patient with bipolar depression who requires metabolic surgery to control diabetes mellitus (DM)?

Consent for Metabolic Surgery in a Patient with Bipolar Depression

The patient herself should provide consent for metabolic surgery as long as she has decision-making capacity, regardless of her bipolar depression diagnosis or medication status. 1

Assessment of Decision-Making Capacity

The presence of bipolar depression does not automatically mean the patient lacks capacity to consent. To determine if the patient has decision-making capacity, assess whether she:

• Can understand information relevant to the decision about metabolic surgery
• Can retain that information
• Can use or weigh that information as part of the decision-making process
• Can communicate her decision 2

A psychiatric diagnosis alone is not sufficient grounds to determine incapacity. Even patients receiving treatment for mental illness should not be assumed incapable of providing valid consent for medical or surgical treatment 2.

Consent Process

When obtaining consent from the patient:

• Provide a comprehensive explanation of risks, benefits, and alternatives
• Discuss both known surgical risks and potential unknown risks
• Balance risks against the consequences of not treating the diabetes
• Explain that metabolic surgery is one component of a comprehensive treatment program 2
• Ensure the patient understands that surgery aims to treat diabetes symptoms but may not "cure" the underlying condition 2

When Surrogate Consent May Be Considered

Surrogate consent (from husband or family members) should only be considered if:

1. The patient demonstrably lacks decision-making capacity
2. The patient has a legally authorized representative
3. Every effort has been made to obtain consent from the patient directly 1

Multidisciplinary Approach

For patients with bipolar depression requiring metabolic surgery:

• Involve a multidisciplinary team including psychiatrist, surgeon, endocrinologist, and psychologist
• Ensure complete consensus regarding patient selection and surgical approach
• Seek outside expert evaluation if there is disagreement within the team 1

Common Pitfalls to Avoid

• Assuming lack of capacity based solely on bipolar diagnosis
• Accepting surrogate consent too readily without proper capacity assessment
• Failing to document capacity assessment
• Not involving psychiatric consultation in the evaluation process 1

Decision Algorithm

1. Assess patient's decision-making capacity with psychiatric consultation
2. If capacity is present → obtain consent directly from patient (Option A)
3. If capacity is questionable → perform formal capacity assessment with psychiatric input
4. If capacity is absent → seek consent from legally authorized representative (Option B - husband)
5. Document assessment process thoroughly regardless of outcome

Remember that treating a competent individual without their informed consent violates ethical norms and disrespects personhood 1. The decision to proceed with metabolic surgery must prioritize the patient's autonomy while ensuring appropriate management of both diabetes and bipolar disorder.