A patient presents brought for medical clearance prior to transport to the county psychiatric facility. She is on a 5150 for being a threat to others. The patient states that she refuses the required screening tests. What do you do?
If she has the capacity to make decisions then she can indeed refuse care. Being placed on a 5150 does not take away her right to make decisions.
On a parallel note patients retain the freedom to make bad choices. A patient with a proximal aortic dissection can choose to refuse surgery, so long as he or she has capacity to make that decision.
To make a decision one must understand the situation, understand the choices, and weigh the potential consequences of each choice. I like to think of that as past, present, and future:
Past – do they understand their condition?
Present – do they understand their choices?
Future – can they express the consequences of each choice?
You go back to the patient and ask her understanding of why she is here. She yells obscenities and speaks of police persecution. You try to calm her down but she can not demonstrate understanding of her condition.
Therefore she does not have capacity to refuse standard screening for medical clearance. Urine toxicology tests are positive for amphetamines.
Take Home Points:
-A decision fundamentally requires understanding choices and anticipating consequences
-“Past, present, and future” helps jog your memory to ensure the patient understands their condition, their choices, and the consequences of each choice.