Assessing Capacity for Decision Making in Schizophrenia: A Case Report

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People with psychiatric impairment may be capable of making wise and thoughtful decisions about their lives.
People with psychiatric impairment may be capable of making wise and thoughtful decisions about their lives.

ATLANTA, Georgia – Cognitive deficits in patients diagnosed with schizophrenia extend across several domains of executive function and are associated with impaired decisional capacity. However, according to a case report presented during the 2016 Annual Meeting of the American Psychiatric Association (APA), patients with schizophrenia may indeed retain the capacity to make decisions about their own medical care.1

“Capacity is an assessment of the individual's ability to form rational decisions and is evaluated by assessing whether a patient can communicate a choice about the proposed treatment, understand his or her medical situation, appreciate the situation and its consequences, and manipulate the information to reach a rational decision” says Sahil Munjal, MD, a PGY-3 resident in psychiatry at New York Medical College and lead author of the study.

Psychiatry Advisor met with Dr Munjal to discuss a case report of a 67-year-old female patient with a diagnosis of schizophrenia and to address the findings of a literature review he conducted with his colleagues at Westchester Medical Center in Valhalla, New York.

This question-and-answer session has been edited for length and clarity.

Psychiatry Advisor: What is the background for this study?

Dr Munjal: Some of us may equate "psychosis" with incapacity, but this case indicates that this is not always true, and that even people who by most measures are psychotic may nonetheless be capable of making wise and thoughtful decisions about their lives. We report a case of a patient with a diagnosis of schizophrenia who presented with worsening auditory hallucinations and progressive weight loss. This patient had a complicated medical course, which eventually led to multiple capacity evaluation requests toward the consultation team. The question of capacity in this patient and the psychiatric population as a whole motivated us to review the literature, since the assumption by many on the medical team is that psychiatric patients do not have the capacity to participate in their medical care. There are many misconceptions floating around about this topic, which we want to address in our poster presentation.

Psychiatry Advisor: What are the main findings?

Dr Munjal: Even though this patient's health was deteriorating and her auditory hallucinations were getting worse, she appeared insightful about her medical problems, understood her prognosis, and wanted comfort care. She understood she had multiple metastases with very poor prognosis along with the fact that a biopsy may yield a diagnosis. She stated, "If it were caught earlier and I was better able to tolerate treatment, it would make sense to know for sure, but now it doesn't make sense. I just want to have no pain in the end.”

In a study by Ganzini and associates,2,3 a total of 395 consultation-liaison psychiatrists, geriatricians, and geriatric psychologists responded to a survey that asked them to rate misunderstandings by clinicians who refer patients for assessment of decision-making capacity. Interestingly, 70% responded that it is common for a practitioner to assume that a patient lacks capacity to make any medical decisions if he or she has a mental illness such as schizophrenia. Furthermore, a meta-analysis conducted by Jeste and colleagues4   to assess the magnitude of impairment in decisional capacity in patients with schizophrenia compared to typical subjects indicates that the presence of schizophrenia does not necessarily mean the patient has impaired capacity.

Related to the present case report, the medical team thought that, given the fact that the patient had a mental illness and was actively hallucinating, she would not have the capacity to refuse any of the proposed treatments and tests even though she was deemed to have capacity each time by various clinicians on the consult service.

Psychiatry Advisor: What should clinicians take away from your case report and review of the literature?

Dr Munjal: A diagnosis of schizophrenia does not automatically render a person unable to make decisions about his or her own medical care. Even patients with severe mental illness may have significant areas of reality testing still intact. Ethically, it is important to consider that patients with chronic mental illness can understand treatment options and express consistent choices.

Psychiatry Advisor: What recommendations do you have for future research as a result of these findings?

Dr Munjal: Medical providers may exclude psychiatric patients from making end-of-life decisions because they are worried about the emotional fragility of the patient and assume patients do not have the capacity to participate in these important decisions. It is important to educate healthcare providers of this common misconception in assessment of decisional capacity. Also, more studies are needed to address this misconception among the experts.

As is true for other areas of functional capacity, the ability of patients with schizophrenia to make competent decisions relates more to their overall cognitive functioning than to the presence or absence of specific symptoms of the disorder.

Click here for more research from the 2016 Annual Meeting of the American Psychiatric Association.

References

1. Munjal S. Assessment of decision making capacity in a psychiatric patient: a common myth. Poster presentation at: 2016 Annual Meeting of the American Psychiatric Association; May 14-18, 2016; Atlanta, GA. P1-119.

2. Ganzini L, Volicer L, Nelson W, Derse A. Pitfalls in assessment of decision-making capacity. Psychosomatics. 2003;44(3):237-243.

3. Ganzini L, Volicer L, Nelson W, Fox E, Derse AR. Ten myths about decision-making capacity. J Am Med Dir Assoc. 2005;6(3Suppl):S100-S104.

4. Jeste D, Depp CA, Palmer BW. Magnitude of impairment in decisional capacity in people with schizophrenia compared to normal subjects: an overview. Schizophr Bull. 2006;32(1):121-128.

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