Respecting the right to refuse: is decision-making capacity disproportionately challenged in patients declining medical care in order to treat?

Abstract

Objective: This study aimed to determine the proportion of capacity challenges for refusal of care, the risk factors that may trigger challenges to capacity and to consider the implications of challenging capacity.

Methods: This retrospective cohort study examined all psychiatric consults placed for decision-making capacity assessment over a 2-year period in an urban community hospital. Data were collected on the reasons for consultation, patient demographics and whether treatment occurred. Statistical analysis, including χ² test for equal proportions, was done to determine whether the proportion of capacity challenges for refusal of care differed from 50%.

Results: 122 consults questioning capacity were identified during the 2-year period, of which 112 (91.8%) were placed in the setting of refusal of care. Males were over-represented (68.9%) in the consults placed for capacity assessment compared with the proportion of males in all hospital admissions (48.8%) (p<0.0001). The odds of being treated increased in the cohort of patients who lacked decision-making capacity compared with those who were deemed to have capacity (OR 4.2 (95% CI 1.4 to 10.4); p=0.002).

Conclusion: This study shows that capacity is challenged overwhelmingly in patients declining medical care. When these patients are decentred from decision making, the odds of completing treatment were more than four times higher.