Who determines the capacity of a psychotic patient requiring surgery?

Determining Capacity in Psychotic Patients Requiring Surgery

The final decision on capacity of a psychotic patient who requires surgery should be made by an expert multidisciplinary team that includes psychiatrists, surgeons, anesthesiologists, and neurologists, not by an individual acting alone. 1

Assessment of Decision-Making Capacity

The assessment of a psychotic patient's capacity to consent for surgery requires a structured approach:

• Capacity must be evaluated based on specific criteria, not on diagnosis alone. Mental illness, including psychosis, does not automatically mean incapacity 1

• For patients to have decisional capacity, they must demonstrate:

  • Sufficient comprehension of the surgical intervention and its risks
  • Ability to judge consequences of the intervention for their own interests
  • Ability to make self-governed decisions based on their insights 1

• Capacity assessment should account for the potential confounding effects of psychiatric symptoms, as psychosis can impair judgment but doesn't necessarily eliminate capacity 1

Decision-Making Process When Capacity Is Questionable

When a psychotic patient's capacity is in question, the following algorithm should be followed:

1. Attempt to treat the underlying psychosis to see if capacity can be restored

   • This may include antipsychotic medications and treatment of contributing factors

2. Formal psychiatric consultation to specifically assess capacity for the surgical decision

   • Documentation must clearly record grounds for capacity determination

3. If capacity is present: Obtain informed consent directly from the patient

   • Refusal of treatment by an adult with capacity is legally binding, even if refusal could result in death 1

4. If capacity is lacking: Move to surrogate decision-making

   • Identify legally authorized representative
   • Consult family members and persons close to the patient
   • Consider best interests of the patient in the "widest sense" (medical, social, psychological) 1
   • Document how the proposed treatment serves the patient's best interests

Special Considerations

• Sliding scale of capacity: More complex or risky surgical procedures require higher levels of capacity 1

• Surrogate decision-making should be extremely rare and requires special vigilance, as surrogates may unknowingly pursue their own interests rather than the patient's 1

• Independent Mental Capacity Advocate should be consulted when a patient lacking capacity requires serious medical treatment and no family members or close friends are available 1

• Emergency situations: Treatment may proceed in the patient's best interests without consent when:

  • Urgent intervention is needed
  • Delay would cause harm
  • Treatment is necessary to prevent deterioration 1

Common Pitfalls to Avoid

• Assuming lack of capacity based solely on psychiatric diagnosis
• Accepting surrogate consent too readily without exhausting efforts to obtain patient consent
• Failing to document capacity assessment thoroughly
• Not involving psychiatric expertise in complex cases
• Allowing surgical teams to make capacity determinations independently without psychiatric input

Monitoring Consent Throughout the Process

Patient consent should be maintained and monitored throughout the surgical process, and patients must be free to withdraw consent at any point 1. This is particularly important in psychotic patients whose mental status may fluctuate.