Preconference Skills Course
While capacity evaluations are part of the “bread and butter” work of consultation-liaison psychiatry, there is little formal training on how to proceed when the clinical situation is highly complex. Often, none of the treating providers feel “expert” on how to proceed in such complex situations, and there is sometimes disagreement on the “right” thing to do, as well as confusion and anxiety about the level of legal risk involved (in intervening with the incapably assenting or refusing patient, versus not intervening). How can the C/L psychiatrist provide leadership and direction in these cases? And should he or she?
Skill in navigating complex clinical decision-making when patients lack decisional capacity best comes from the lived experience of collaboratively working through these situations. For this course, we utilize real clinical cases in a workshop format that serve as the springboard to discuss relevant topics ranging from ethical and legal considerations to the considerations of hospital administrators and the on-the-ground clinicians providing care. When the rubber hits the road and a patient adamantly (and incapably) refuses a needed medical or surgical intervention, what should be done, how and when should it be done, and what are the risks?
Dr. Kruse will introduce the session, briefly review the basics of decisional capacity assessment (including potential pitfalls), and provide case vignettes of varying complexity for participants to consider, with expert consultation from the multidisciplinary panel gathered, including representatives from medicine, psychiatry, ethics, law, and hospital administration/quality improvement. Dr. Wenger, ethics committee chair at UCLA, will discuss ethical approaches to clinical decision-making when a patient lacks decisional capacity. Johanna Klohn, JD, Chief Risk Officer at UCLA, will provide the legal context – what are the risks of intervening (vs not intervening) when a patient lacks capacity to refuse or accept an intervention? Dr. Busuttil will provide the perspective of an internal medicine hospitalist, the frontline providers in these cases, who generally have a different level of experience and comfort with involuntary detentions/interventions compared to psychiatrists (who commonly involuntarily detain and treat psychiatrically ill patients under certain conditions, utilizing civil commitment laws). She will speak to what the medicine hospitalist needs from psychiatry and other multidisciplinary team members. Dr. Cheung will speak from a quality improvement perspective on the “medical incapacity hold,” an intervention developed to keep non-psychiatrically ill medically hospitalized patients safely detained when they lack capacity to leave against medical advice, are requesting or attempting to leave, and would be at risk for grave harm if allowed to do so. Finally, Dr. Strouse will moderate the discussion, and will also speak to the role and the considerations of hospital administration in such complex cases.