NEW ORLEANS ― Evaluating a patient’s capacity to make decisions about his or her personal healthcare can present a significant challenge for physicians, but evaluating intoxicated patients has its own set of unique complications.
When assessing an intoxicated patient, the first important distinction to bear in mind is the difference between capacity and competency, according to David Yankura, MD, medical director of coding and compliance at Western Psychiatric Institute and Clinic of the University of Pittsburgh Medical Center in Pennsylvania.
Capacity is determined through clinical assessment by a physician, whereas competency is a legal issue.
“Everyone is deemed to be competent unless a judge determines you have the power to make no decisions at all, and that’s the end of the story, but capacity is a bit more nuanced,” Dr Yankura told delegates attending the Institute of Psychiatric Services (IPS): The Mental Health Services 2017 Conference.
Varying degrees of capacity are required to make decisions in light of different levels of risk and benefit: a potentially suicidal patient consenting to be admitted to the hospital (low risk, high benefit) requires a much different level of capacity than would be the case if that same patient was deciding he or she was ready to leave the hospital (high risk, low benefit).
When conducting a capacity assessment, Dr Yankura recommended use of CURVES: Choose and Communicate, Understand, Reason, Value, Emergency, Surrogate. These steps for determining medical decision-making capacity and the need for emergency treatment in the acute setting can be a lifesaver in a psychiatric emergency. The CURVES approach was originally published in 2010 in an article in Chest.
CURVES Ahead
First, Choose and Communicate. Can the patient talk with the physician and communicate a choice? If so, does his or her decision change every couple of minutes? If so, that person does not possess the capacity to make a decision, Dr Yankura said.
Next, Understand. Does the patient understand the risks, benefits, alternatives, and consequences of the decisions he or she is being asked to make? “Make sure they’re able to repeat back what you said in their own words,” Dr Yankura advised. “If they’re smiling and nodding while you discuss risks and benefits, that doesn’t necessarily mean they understand them.”
Then, Reason. If the patient is able to understand, is he or she also able to reason and provide logical explanations for this decision?
Next, Values. Is the decision the patient is making in accordance with his or her values? “There’s a big difference between a lifelong Jehovah’s Witness refusing a blood transfusion vs a lifelong atheist suddenly refusing all medical care because of religious reasons,” he said.
Is there an Emergency, or a serious and imminent risk to the patient’s well-being? In such cases, capacity assessment can wait until the emergency is managed and ongoing care begins. “You’re not necessarily thinking about capacity if someone has used a bunch of heroin and is barely breathing,” he said.
Lastly, Surrogate. If the patient is deemed incapable, is a surrogate present to make decisions for the patient?
When the patient who is being assessed has ingested a substance of some kind, determination of capacity can be difficult. It is important to attempt to establish the patient’s level of intoxication.
One approach is to determine blood alcohol concentration (BAC) through the use of a breathalyzer. Dr Yankura cited his own reservations in regard to this approach, because it can only be used to when alcohol is the intoxicating substance involved, and alcohol tolerance can vary widely between individuals.
The majority (84%) of persons who consume alcohol ― including both those who do not drink alcohol regularly and those who are long-term drinkers ― will be visibly intoxicated when the BAC is about 200 mg/dL, but some drinkers have very high tolerance, he cautioned.
Long-term vs Short-term Users
A 2013 study by Kalen R. Olson, MD, and colleagues found that a checklist of alcohol intoxication symptoms correlated poorly with measured BAC in long-term users compared to short-term users. “Again, I think the piece here that’s missing is tolerance,” Dr Yankura noted.
“For chronic users, the breathalyzer may never be at 0. They may live at over 300 or 400 mg/dL.” In the study by Dr Olson, estimations of BAC by medical professionals correlated better among all patients, likely owing to the fact that the healthcare providers took into consideration individual tolerance, he added.
Importantly, withdrawal is not accounted for when using the “sober by the numbers” approach. “Some people live their lives at a high BAC, and a relative decline can throw them into withdrawal,” he cautioned. “If you’re waiting for .08 or 0 BAC, you’re going to have a lot of folks in withdrawal in your ER, and you’re going to have to manage that before even attempting to determine capacity.”
Determining clinical sobriety can also be useful in gauging varying degrees of capacity of persons who are under the influence of any substance, not only alcohol. Such an approach to assessment is favored by Dr Yankura.
“If a patient is drunk and wants a nicotine lozenge, I’ll let them decide that as long as they can stay awake long enough not to choke on it,” he said. “If a patient wants to leave after saying they’re suicidal, I’d wait until they were more clinically sober before talking with them and deciding if I’m going to let them go.”
When a patient is deemed incapable, decision making should be postponed until capacity is restored, if possible, and then the evaluation can proceed, said Dr Yankura.
According to Jack Rozel, MD, MSL, associate professor of psychiatry at Pittsburgh School of Medicine, risk management comes heavily into play when assessing capacity in intoxicated patients.
“It’s about making difficult decisions well, without all the information that we’d like, and making them fairly quickly,” he said.
Dr Yankura and Dr Rozel have disclosed no relevant financial relationships.
Institute of Psychiatric Services (IPS): The Mental Health Services 2017 Conference. Presented October 20, 2017.
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