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Administer NAC
19%
10/53
Cancel the NAC order
9%
5/53
Involve the patient's husband to guide medical care
26%
14/53
Force the patient to accept NAC
4%
2/53
Consult psychiatry
30%
16/53
Select Answer to see Preferred Response
This vignette describes a patient whose decision-making capacity is cast into doubt by her suicidal attempt. The best next step is to involve the patient's husband to guide medical care. This patient's suicidality implies a temporary lack of rationality. In most suicide attempts, individuals do not have an unambiguous desire to die. Those who attempt to commit suicide lack capacity to refuse therapies that may ameliorate the harms of their suicidal acts. In this case, the patient is asymptomatic despite worsening liver function, so there is time to involve a surrogate decision-maker to help guide care without forcing treatment against the patient's will. Giordano and Duffy advise on gauging decision-making capacity. Capacity is a medical decision determined by a physician, based on an evaluation of the patient's ability to understand the risks, benefits, and alternatives to a choice. Patients with capacity may make decisions that are inconsistent with the recommendations made by their healthcare providers, but this does not reflect a lack of capacity to decide (i.e. ongoing tobacco use). Matthews notes that if a physician concludes that a patient has impaired decision-making capacity, this is often is sufficient to legally declare a patient's lack of competency. However, competency is a legal term ultimately defined by the court, not by the physician. In these situations, the physician must work with the patient's surrogate (such as a family member or friend) or designated power of attorney in the decision processes involved in the patient's care. Incorrect Answers: Answer 1 and 4: NAC should be administered soon, but there is sufficient time for patient buy-in and to recruit supportive family members to help guide care. Answer 2: NAC is a low-cost, high-efficacy treatment. It should not be canceled simply because the patient refuses, given her suicidality. Answer 5: Psychiatry consultation is not necessary to determine a patient's decision-making capacity. The attending physician can perform this assessment.
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