Annotated Abstracts of Journal Articles
2015, 4th Quarter


Annotation by Christina Scully, MD
January 2016


Jimenez XF, Esplin BS, Hernandez JO: Capacity consultation and contextual complexities: depression, decisions, and deliberation
Psychosomatics 2015; 56(5):592-597

This article, published in Psychosomatics’ Case Reports format, presents a challenging clinical case vignette, wherein the consultant has been asked to assess for medical decision-making capacity to refuse life saving treatment. The case and accompanying analysis highlights the complex ethical, medical and psychosocial complexities involved in consult psychiatry capacity determination.

The case illustrates competing components of the assessment, including patient preference, medical uncertainty, legal obligations, family input, physician comfort/discomfort with end of life issues and comorbid psychiatric illness. The analysis depicts a narrow to broad scope of approach. First, in the narrowest sense, a strict, cognitive capacity assessment, with the components of communicating a clear, consistent choice; understanding the indications, risks, and benefits associated with treatment; appreciation of how the situation applies directly to the person; and rational manipulation of information free from the effects of coercion, untreated mental illness or other pressures; to broader elucidation of moral and ethical dimensions that often arise in clinical practice.

This analysis demonstrates how a narrow focus on the elements of cognitive capacity may lead to overly simplistic, disparate conclusions. Next, the authors present an alterative, clinically-focused method, the Four Quadrants Approach to Clinical Ethical Dilemmas, which first advises defining whether ongoing medical treatment is futile and understanding a patient’s prognosis; essentially, understanding the medical facts. This approach then suggests a review of patient preferences, both previously and actively stated wishes that review legal documentation of advanced directives/living will and code status. Then, it proceeds to consideration of quality of life concerns (comfort, pain, mobility and daily function), and lastly, contextual considerations, including legal, financial, familial and other factors.