If the diagnosis is uncertain, the goals of treatment are unclear, or the clinician is not confident of what steps to take next, then consultation with another individual with relevant expertise is prudent. This is particularly true with patients who have multiple problems and perhaps multiple possible diagnoses or with those who are especially difficult interpersonally. Be prepared to document the patient’s response to treatment in a manner that may be helpful in the future and, with the patient’s permission, to communicate in a collaborative manner with others who are involved in the patient’s care—such as a psychotherapist, a primary care provider, or family members.
Informed consent
Informed consent is the legal and ethical foundation of ethical health care.4 It is predicated on the therapeutic relationship and involves the provision of information, the decision-making capabilities of the patient, and authentic voluntarism.5
The therapeutic relationship is deeply respectful of the patient and places primacy on promoting health and alleviating suffering as the basis for any treatment recommendation. It is dedicated to beneficence and nonmaleficence (ie, seeking good and avoiding harm in the patient’s care).
The information-sharing element of informed consent stresses the importance of communicating accurate, appropriate, and balanced information regarding the risks and benefits of treatment and treatment alternatives—including the risks and benefits of no treatment. Moreover, information sharing should incorporate the attitudes and values of the patient to the fullest extent possible.
It can be difficult to know how much information to bring into the discussion with the patient. More often than not, the “reasonable person” standard guides how much information to share—in other words, what would a reasonable person need or wish to know to make a decision? If the likelihood of benefit is great and the adverse effects are limited and far less burdensome than the illness itself, then the information to be shared will be far less than if the promise of benefit is small and the adverse effects are extensive, very burdensome, or severe. In particular, if adverse effects of treatment are rare but are life-threatening, they should be made explicit in the consent dialogue.
Furthermore, informed consent requires that the patient have sufficient decisional capacity to understand the question at hand. The assessment of decisional capacity is a clinical judgment of the patient’s ability to provide an informed, voluntary decision. The evaluation of decisional capacity involves careful exploration of 4 elements:
• The patient’s capacity to communicate and thus his or her ability to express a preference
• The patient’s capacity to understand relevant information
• The patient’s capacity to think through choices in a rational manner
• The patient’s capacity to appreciate the nature of his illness and the recommended treatment in the context of his life
The final element of informed consent is voluntarism, ie, the patient’s ability to act in accordance with an authentic sense of what is right for him, in light of his own life context and belief system.6
Voluntarism is contingent on the patient’s developmental level; consider whether his illness affects his ability to discern his preferences, whether there are psychological or cultural factors that shape his sense of being free to make the decision, and whether the context supports autonomous decision making. A child, for instance, will be less able to offer an authentic, uncoerced decision than an adult, and a prisoner with mental illness who resides in a locked facility will be less able to offer an authentic, uncoerced decision than an outpatient with mental illness who resides in a community setting.
