Quantitative Analysis of Ethical Complexities Underlying Psychiatric Decision-making Capacity Evaluations: Prevalence...

The ethical complexity within psychiatric evaluations of decision-making capacity (DMC) often involves more than determining whether a patient retains DMC. Some psychiatrists propose that DMC evaluation may be requested due to distress regarding additional ethical dilemmas, even when capacitation status is not questioned. The present study quantitatively illustrates this additional ethical complexity and provides greater transparency regarding additional areas that may require psychiatric facilitation of care when consulted for the evaluation of DMC.

A total of 145 DMC evaluation case encounters were retrospectively analyzed for the presence of 27 total additional ethical context factors. Factor prevalence and number of factors per case were calculated. Cooccurrence of ethical context factors was determined through Fisher exact test pairwise comparisons.

Almost all cases (93.1%) featured ≥1 additional ethical context factor (range = 0 to 13 factors/case). The most common factors included inpatient treatment refusal or nonadherence (34.5%), leaving against medical advice (26.2%), concerns about nonadherence to outpatient treatment (25.7%), surrogate determination (22.1%), palliative care and hospice consideration (20.7%), and disposition conflict (20.7%). Several ethical context factors demonstrated significant pairwise cooccurrence, many of which involved mandatory reporting of abuse and neglect.

Clinical scenarios encountered in DMC evaluations often contain ethical complexities beyond clarifying capacitation status. Often, consultation with psychiatrists to evaluate DMC may reflect the underlying desire for management of additional ethical context factors. The unique skillset of consultation liaison psychiatrists can help both patients and medical teams navigate these complicated clinical trajectories. Screening for additional ethical context factors in DMC evaluations may enable the facilitation of optimal care.