Department of Psychiatry and Psychology, Cleveland Clinic, Cleveland, OH.
Center for Ethics, Humanities, and Spiritual Care, Cleveland Clinic, Cleveland, OH.
Psychosomatics. 2017 Sep-Oct;58(5):483-489. doi: 10.1016/j.psym.2017.03.013. Epub 2017 Mar 28.
Psychosocial and ethical variables influence physicians in requesting decision-making capacity (DMC) evaluations. Previous authors have classified certain DMC evaluation requests as "unwarranted" when there is no explicit suspicion or evidence that the patient might lack DMC.
To explore psychosocial and ethical reasons motivating both "warranted" and "unwarranted" DMC evaluation requests by physicians in the medical setting.
A retrospective electronic health record review was approved by the institutional review board. All psychiatric consultation requests identified as DMC evaluation requests between January 1, 2012 and December 31, 2012 were assessed independently by 2 reviewers. Each reviewer identified each DMC evaluation request as "warranted" vs "unwarranted." Unwarranted DMC evaluation requests were defined as those lacking explicit suspicion that the patient might lack DMC or those with explicit evidence of a patient with blatantly impaired DMC. We hypothesized that most (over half) DMC evaluation requests would be deemed unwarranted. Descriptive statistics, chi-square/Fisher exact tests, and t-test/ANOVA were used.
A total of 146 DMC evaluations were reviewed, and 83 (56.8%) of these were deemed unwarranted. Of these, most were likely driven by a previous neuropsychiatric disturbance (p < 0.001). Various other psychosocial and ethical patterns were identified (i.e., the practice of defensive medicine and guardianship concerns).
Over half of DMC evaluation requests in a general medical setting were unwarranted. Many such requests were motivated by unarticulated psychosocial and ethical factors. DMC evaluation requests appear to serve as a means for indirectly resolving various psychosocial and ethical dilemmas beyond assessing DMC itself. Implications and future directions are discussed.
心理社会和伦理变量会影响医生提出决策能力（DMC）评估的请求。先前的作者将某些 DMC 评估请求归类为“不必要的”，即没有明确怀疑或证据表明患者可能缺乏 DMC。
探讨医生在医疗环境中提出“有必要的”和“不必要的”DMC 评估请求的心理社会和伦理原因。
一项回顾性电子病历审查获得机构审查委员会批准。所有在 2012 年 1 月 1 日至 2012 年 12 月 31 日期间被确定为 DMC 评估请求的精神科会诊请求均由 2 名评审员独立评估。每位评审员将每个 DMC 评估请求标记为“有必要的”或“不必要的”。不必要的 DMC 评估请求被定义为那些缺乏对患者可能缺乏 DMC 的明确怀疑或那些明确存在患者明显受损的 DMC 的证据。我们假设大多数（超过一半）DMC 评估请求将被认为是不必要的。使用描述性统计、卡方/Fisher 精确检验和 t 检验/方差分析。
共审查了 146 次 DMC 评估，其中 83 次（56.8%）被认为是不必要的。其中，大多数可能是由以前的神经精神障碍引起的（p < 0.001）。还确定了各种其他心理社会和伦理模式（即，防御性医疗和监护担忧的实践）。
在一般医疗环境中，超过一半的 DMC 评估请求是不必要的。许多此类请求是由未阐明的心理社会和伦理因素驱动的。DMC 评估请求似乎是间接解决 DMC 评估本身之外的各种心理社会和伦理困境的一种手段。讨论了其影响和未来方向。
