(155) Consultation for Decision-Making Capacity in C-L Psychiatry Service: Characterization by Decision-Type and Outcomes

‎Background/Significance: Up to 25% of psychiatry consults are estimated to be regarding decision-making ‎capacity. Decision to consult for capacity evaluation is influenced by numerous factors, and is impacted by unconscious ‎bias as capacity consults are disproportionately placed for racial minority groups (Garrett, 2023). A study of randomly ‎sampled inpatients showed 31.4-47.8% lacked decision-making capacity regarding current treatment (Raymont, 2004). ‎Further characterization of capacity consults, their utilization, and their outcomes is important as consults often involve ‎situations that present substantial risk with little potential benefit, like capacity to leave the hospital against medical ‎advice (AMA). We aimed to investigate these factors at our institution.‎

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Methods: All consultations in a one-year period from our tertiary care center in which consultation-liaison ‎psychiatry assessed decisional capacity. Consultations were identified through search for reported reason for consult ‎and notes which indicated capacity assessment was provided. These were categorized based on decision type for ‎which capacity was evaluated, including discharge against medical advice (AMA), surgery/procedure, medical decision-‎making, and disposition. In some consultations, capacity for more than one decision was evaluated.‎

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Results: Of 196 consultations reviewed, results quantified by decision type indicated: 82 (41.8%) for ‎disposition, 58 (29.6%) for AMA discharge, 34 (17.4%) for procedure or surgery, and 38 (19.4%) regarding all other ‎medical decisions. Of those assessed for AMA discharge, 22.4% were deemed to have capacity, 58.6% lacked capacity, ‎and 19.0% were unable to be assessed. Of those assessed for disposition, 31.7% were deemed to have capacity, 62.2% ‎lacked capacity, and 4.8% were unable to be assessed. Of those assessed for surgery/procedure, 32.4% were deemed ‎to have capacity, 52.9% lacked capacity, and 14.7% were unable to be assessed. For all other medical decisions, 31.6% ‎were deemed to have capacity, 52.6% lacked capacity, and 15.8% were unable to be assessed. Additional services by ‎consultant were provided in 77.6% of consults reviewed. The most common services provided were medication ‎management/reconciliation (40.8%), education to team/staff (28.6%), delirium/agitation management (27.0%), ‎education to patient/family regarding diagnosis (19.4%) or medications (16.3%), obtaining collateral (16.3%), bedside ‎psychotherapy (13.3%), and bedside cognitive testing (5.6%).‎

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Discussion: The most frequent decision type assessed was disposition, followed by AMA discharge. Patients ‎assessed for AMA discharge were least likely to be deemed to have capacity, not unexpectedly as this decision is often ‎high-risk, low-benefit. Additional services were provided in 77.6% of consults, most frequently medication ‎management/reconciliation, presenting additional added value. We plan to examine additional demographic ‎information about patients, diagnoses, and the services requesting capacity consult.‎

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Conclusion: For all consult types, patients were more frequently found to lack than to have capacity, ‎presenting significant implications pertaining to patient autonomy. Capacity consults also provided an additional ‎interface between high-risk patients and psychiatry, increasing added value beyond the risk management implicit in ‎capacity evaluation.‎

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References: ‎
‎1. Garrett WS, Verma A, Thomas D, Appel JM, Mirza O. Racial Disparities in Psychiatric Decisional Capacity ‎Consultations. Psychiatry Serv. 2023;74(1):10-16. doi:10.1176/appi.ps.202100685‎
‎2. Raymont V, Bingley W, Buchanan A, et al. Prevalence of mental incapacity in medical inpatients and associated risk ‎factors: cross-sectional study. Lancet. 2004;364(9443):1421-1427. doi:10.1016/S0140-6736(04)17224-3‎