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Jia Wang is an Assistant Professor, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine Laurence B. McCullough, PhD, is a Professor, Department of Medicine and Center for Medical Ethics and Health Policy, Baylor College of Medicine. John H. Coverdale, MD, MEd, is a Professor, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine. Anu Matorin, MD, is an Associate Professor, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine. Elizabeth H. David, MD, is an Assistant Professor, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine. Frank A. Chervenak, MD, is a Professor and Chairman, Department of Obstetrics and Gynecology, New York Weill Cornell Medical Center. Asim A. Shah, MD, is an Associate Professor, Menninger Department of Psychiatry and Family and Community Medicine, Baylor College of Medicine; and the Chief of Psychiatry, Ben Taub Hospital.
Asim A. Shah discloses fees for non-continuing medical education services from Otsuka; and contracted research for Roche, Bristol-Myers Squibb, and Synchroneuron. The remaining authors have no relevant financial relationships to disclose.
The patient is a severely immunocompromised woman older than age 30 years who is 22 weeks pregnant. She is unmarried and has two young children. With a history of cancer, she came to the hospital complaining of pain, and her work-up revealed diffusely metastatic cancer, including brain lesions and imminent herniation, for which urgent surgical resection was recommended. However, she exhibited a fluctuating mental status and the treating team questioned whether she had decision-making capacity. Psychiatric clinicians were asked to evaluate the patientâ[euro](TM)s decision-making capacity.
<bold>Discussion</bold>
In cases like this one, what is the consulting psychiatristâ[euro](TM)s role in planning for the patientâ[euro](TM)s treatment? We propose the following framework to guide the evaluation: <list> <list_item><para>
Assess the patientâ[euro](TM)s decision-making capacity. </list_item> <list_item><para>
Determine the patientâ[euro](TM)s values and what her potential decisions are based on those values. </list_item> <list_item><para>
Maximize the patientâ[euro](TM)s opportunity to express concerns even if her decision-making capacity is diminished. </list_item> <list_item><para>
Consider goals of the treatment based on prognosis and gestational age. </list_item> <list_item><para>
Identify countertransference in her treatment providers (including a surrogate decision-maker). </list_item></list>
<bold>Decision-Making Capacity</bold>
Numerous articles have talked about the concept of capacity, with the elements of intact decision-making a well-known topic (<bold>Table 1</bold>).1,2 In...