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Appel JM. Decisional Capacity After Dark: Is Autonomy Delayed Truly Autonomy Denied? Camb Q Healthc Ethics 2024; 33:260-266. [PMID: 37366147 DOI: 10.1017/s096318012300035x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2023]
Abstract
The model for capacity assessment in the United States and much of the Western world relies upon the demonstration of four skills including the ability to communicate a clear, consistent choice. Yet such assessments often occur at only one moment in time, which may result in the patient expressing a choice to the evaluator that is highly inconsistent with the patient's underlying values and goals, especially if a short-term factor (such as frustration with the hospital staff) distorts the patient's preferences momentarily. These challenges are particularly concerning in cases, which arise frequently in hospital settings, in which patients demand immediate self-discharge, often during off-hours, while faced with life-threatening risks. This paper examines the distinctive elements that shape such cases and explores their ethical implications, ultimately offering a model for such situations that can be operationalized.
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Affiliation(s)
- Jacob M Appel
- Professor of Psychiatry and Medical Education, Director of Ethics Education in Psychiatry, Assistant Director, Academy for Medicine & the Humanities, Attending Physician, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, USA
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Mirza OF, Appel JM. Capacity Reconceptualized: From Assessment Tool to Clinical Intervention. Camb Q Healthc Ethics 2024; 33:35-39. [PMID: 36825923 DOI: 10.1017/s0963180123000105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
Capacity evaluation has become a widely used assessment device in clinical practice to determine whether patients have the cognitive ability to render their own medical decisions. Such evaluations, which might be better thought of as "capacity challenges," are generally thought of as benign tools used to facilitate care. This paper proposes that such challenges should be reconceptualized as significant medical interventions with their own set of risks, side effects, and potentially deleterious consequences. As a result, a cost-benefit analysis should be implemented prior to imposing such capacity challenges, and efforts should be made to minimize such challenges in situations where they are unlikely to alter the course of treatment.
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Affiliation(s)
- Omar F Mirza
- Department of Psychiatry, Harlem Hospital, New York, New York, USA
| | - Jacob M Appel
- Department of Psychiatry and Medical Education, Mount Sinai's Icahn School of Medicine, New York, New York, USA
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Zambrano J, Celano CM, Onyeaka H, Rodriguez AM, Shea T, Ahn-Horst R, Grossman M, Mullersman K, Ordoñez AS, Smith FA, Beach S. Ethnoracial disparities in care on a consultation-liaison service at an academic hospital. Gen Hosp Psychiatry 2024; 86:50-55. [PMID: 38070241 PMCID: PMC10843593 DOI: 10.1016/j.genhosppsych.2023.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 10/13/2023] [Accepted: 11/25/2023] [Indexed: 01/27/2024]
Abstract
BACKGROUND There is currently an increasing recognition of and focus on structural and institutional racism and its impacts on health disparities. In psychiatry and mental health, research has focused on racial and ethnic disparities in the availability and utilization of mental health services, care in emergency departments, and inpatient psychiatric services. Little is known about disparities in care on general hospital psychiatry consultation-liaison (CL) services. METHODS In this exploratory study, we conducted a retrospective chart review using electronic health record (EHR) data of all adults (≥ 18 years of age) admitted to inpatient medical or surgical floors at an urban academic medical center for whom a psychiatric consultation was requested during the study period. We examined differences by race and ethnicity in: rates of consultation requests; use of legal holds, constant observation, restraints; follow-up by the CL service; and ultimate disposition. RESULTS The service received 310 unique consults during the study period. Compared to hospital-wide numbers, Black-identifying patients were over-represented in our sample (11.9% vs 6.6%), while Latinx patients were underrepresented (6.1% vs 9.8%). Of the clinical and outcome variables collected, there were higher odds of being placed on a legal hold both prior to (OR 2.6) and after the consult question (OR 2.98) and in the odds of having a one-to-one observer prior to (OR 2.47) and after (OR 2.9) the initial consult visit for Black-identifying patients, when adjusting for confounders. There were no other measurable differences in care or outcomes by racial or ethnic categories. CONCLUSION Black-identifying patients may be more likely to receive psychiatric consultation and be placed on legal holds because of a combination of chronic adverse social determinants of health and race-based bias. Conversely, Latinx patients may be less likely to receive psychiatric consultation because of language barriers among other factors. The lack of disparities identified in other domains may be encouraging, but larger studies are needed. Further research is also needed to identify causality and interventions that could help close the gap in care and outcomes for racial and ethnic minorities.
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Affiliation(s)
- Juliana Zambrano
- Massachusetts General Hospital, Department of Psychiatry, USA; Harvard Medical School, USA.
| | - Christopher M Celano
- Massachusetts General Hospital, Department of Psychiatry, USA; Harvard Medical School, USA
| | - Henry Onyeaka
- Massachusetts General Hospital, Department of Psychiatry, USA; Harvard Medical School, USA
| | | | - Timothy Shea
- Massachusetts General Hospital, Department of Psychiatry, USA; Harvard Medical School, USA
| | - Rosa Ahn-Horst
- Massachusetts General Hospital, Department of Psychiatry, USA; Harvard Medical School, USA
| | - Mila Grossman
- Massachusetts General Hospital, Department of Psychiatry, USA; Harvard Medical School, USA
| | - Katherine Mullersman
- Massachusetts General Hospital, Department of Psychiatry, USA; Harvard Medical School, USA
| | - Andrea Soto Ordoñez
- Massachusetts General Hospital, Department of Psychiatry, USA; Harvard Medical School, USA
| | - Felicia A Smith
- Massachusetts General Hospital, Department of Psychiatry, USA; Harvard Medical School, USA
| | - Scott Beach
- Massachusetts General Hospital, Department of Psychiatry, USA; Harvard Medical School, USA
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Lekas HM, Lewis C, Bradley MV, Pahl K. The Color of Autonomy: Examining Racial Inequity in Coercive Institutional Practices. Psychiatr Serv 2023; 74:1189-1191. [PMID: 37143336 DOI: 10.1176/appi.ps.20220595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
Two articles recently published in this journal identified racial inequities in routine psychiatric practice. This Open Forum discusses the need for a paradigm shift in inequities research. The two articles reviewed here, one by Shea and colleagues on racial-ethnic inequities in inpatient psychiatric civil commitment and one by Garrett and colleagues on racial-ethnic disparities in psychiatric decisional capacity consultations, are examples of the new research gaze. Four topics are identified for enhancing understanding of racism and other forms of structural exclusion in psychiatric practice: medical authority and power imbalance between providers and patients, involuntary psychiatric commitment and requests for decisional capacity consultations as strategic research events, limited use of theory, and limitations of the literature on psychiatric inequities.
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Affiliation(s)
- Helen-Maria Lekas
- Division of Social Solutions and Services Research, Center for Research on Cultural and Structural Equity in Behavioral Health, Nathan S. Kline Institute for Psychiatric Research, Orangeburg, New York (Lekas, Lewis, Pahl); Department of Psychiatry, Grossman School of Medicine, New York University, New York City (all authors); Veterans Affairs New York Harbor Healthcare System-Brooklyn, New York (Bradley)
| | - Crystal Lewis
- Division of Social Solutions and Services Research, Center for Research on Cultural and Structural Equity in Behavioral Health, Nathan S. Kline Institute for Psychiatric Research, Orangeburg, New York (Lekas, Lewis, Pahl); Department of Psychiatry, Grossman School of Medicine, New York University, New York City (all authors); Veterans Affairs New York Harbor Healthcare System-Brooklyn, New York (Bradley)
| | - Mark V Bradley
- Division of Social Solutions and Services Research, Center for Research on Cultural and Structural Equity in Behavioral Health, Nathan S. Kline Institute for Psychiatric Research, Orangeburg, New York (Lekas, Lewis, Pahl); Department of Psychiatry, Grossman School of Medicine, New York University, New York City (all authors); Veterans Affairs New York Harbor Healthcare System-Brooklyn, New York (Bradley)
| | - Kerstin Pahl
- Division of Social Solutions and Services Research, Center for Research on Cultural and Structural Equity in Behavioral Health, Nathan S. Kline Institute for Psychiatric Research, Orangeburg, New York (Lekas, Lewis, Pahl); Department of Psychiatry, Grossman School of Medicine, New York University, New York City (all authors); Veterans Affairs New York Harbor Healthcare System-Brooklyn, New York (Bradley)
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MacIntyre MR, Cockerill RG, Mirza OF, Appel JM. Ethical considerations for the use of artificial intelligence in medical decision-making capacity assessments. Psychiatry Res 2023; 328:115466. [PMID: 37717548 DOI: 10.1016/j.psychres.2023.115466] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 09/03/2023] [Accepted: 09/04/2023] [Indexed: 09/19/2023]
Abstract
The rapid advancement of artificial intelligence (AI) and machine learning are providing new tools to clinicians. AI tools have the potential to process vast amounts of data in a short amount of time, providing new insights and changing how we approach complicated healthcare problems. AI has the potential to assist clinicians in medical decision-making capacity assessments by providing additional insights to an evaluation process that currently lacks universal objective standards. However, despite the promise of AI in this setting, there remain significant concerns making it unlikely to replace human evaluators anytime soon. AI remains highly susceptible to biased inputs and thus biased decisions, raises questions about autonomy, and creates uncertainty for who is accountable for the ultimate decision of capacity. In this paper we explore these ethical considerations of using AI for capacity assessments. While we acknowledge AI may not be ready to replace physicians in determining patient medical-decision making capacity, these new technologies have significant near-term potential as a tool to screen patients, uncover physician biases, and guide next steps after a capacity determination has been made.
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Affiliation(s)
- Michael R MacIntyre
- Department of Psychiatry and Biobehavioral Sciences at the David Geffen School of Medicine, University of California, Los Angeles, 760 Westwood Plaza, Los Angeles, CA, U.S.A..
| | - Richard G Cockerill
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago Pritzker School of Medicine, 5815 S. Maryland Ave., Chicago, Illinois, USA
| | - Omar F Mirza
- Department of Psychiatry, NYC Health+Hospitals/Harlem, 506 Lenox Ave., New York, New York, USA
| | - Jacob M Appel
- Department of Psychiatry and Medical Education, Mount Sinai's Icahn School of Medicine, 1 Gustave L. Levy Pl., New York, New York, USA
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Khandai AC, Mittal LP. Diversity, Equity, and Inclusion in Consultation-Liaison Psychiatry: Advancing the Field Through Shared Values. J Acad Consult Liaison Psychiatry 2023; 64:319-321. [PMID: 37301323 DOI: 10.1016/j.jaclp.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 06/04/2023] [Indexed: 06/12/2023]
Affiliation(s)
- Abhisek C Khandai
- Department of Psychiatry, UT Southwestern Medical Center, Dallas, TX.
| | - Leena P Mittal
- Department of Psychiatry, Brigham and Women's Hospital, Boston, MA
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Caravella RA, Ying P, Siegel C, Vaughn R, Deutch AB, Caroff A, Madanes S, Ackerman MG, Lewis C. Quality Improvement Framework to Examine Health Care Disparities in Behavioral Emergency Management in the Inpatient Medical Setting: A Consultation-Liaison Psychiatry Health Equity Project. J Acad Consult Liaison Psychiatry 2023; 64:322-331. [PMID: 37060945 DOI: 10.1016/j.jaclp.2023.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 04/05/2023] [Accepted: 04/09/2023] [Indexed: 04/17/2023]
Abstract
BACKGROUND De-escalation of behavioral emergencies in the inpatient medical setting may involve restrictive clinical interventions that directly challenge patient autonomy. OBJECTIVE We describe a quality improvement framework used to examine associations between patient characteristics and behavioral emergency de-escalation strategies. This project may inform other Consultation-Liaison Psychiatry teams seeking to promote equity in care. METHODS We examined behavioral emergency response team (BERT) management at an urban, tertiary-care medical center in the United States over a 3-year period. BERT data from an existing dataset were combined with demographic information from the hospital's electronic medical record. Race and ethnic identities were categorized as Black, Hispanic, Asian, White, and unknown. BERT events were coded based on the most restrictive intervention utilized per unique patient. Cross-tabulations and adjusted odds ratios from multivariate logistic regression were used to identify quality improvement targets in this exploratory project. RESULTS The sample included N = 902 patients and 1532 BERT events. The most frequent intervention reached was verbal de-escalation (n = 419 patients, 46.45%) and the least frequent was 4-point restraints (n = 29 patients, 3.2%). Half of BERT activations for Asian and a third for Hispanic patients required interpreter services. Anxiety and cognitive disorders and 2 BERT interventions, verbal de-escalation, and intramuscular/intravenous/ medications, were significantly associated with race/ethnic category. The most restrictive intervention for BERTs involving Black and Asian patients were verbal de-escalation (60.1%) and intramuscular/intravenous(53.7%), respectively. These proportions were higher compared with other race/ethnic groups. There was a greater percentage of patients from the unknown (6.3%) and Black (5.9%) race/ethnic groups placed in 4-point restraints compared with other groups (3.2%) that did not reach statistical significance. A logistic regression model predicting 4-point restraints indicated that younger age, multiple BERTs, and violent behavior as a reason for BERT activation, but not race/ethnic group, resulted in significantly higher odds. CONCLUSIONS This project illustrates that a quality improvement framework utilizing existing clinical data can be used to engage in organizational introspection and identify potential areas of bias in BERT management. Our findings suggest opportunities for further exploration, enhanced education, and programmatic improvements regarding BERT intervention; 4-point restraints; interpreter services; and the influence of race on perception of psychopathology.
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Affiliation(s)
- Rachel A Caravella
- Department of Psychiatry, New York University, Grossman School of Medicine, New York, NY.
| | - Patrick Ying
- Department of Psychiatry, New York University, Grossman School of Medicine, New York, NY
| | - Carole Siegel
- Department of Psychiatry, New York University, Grossman School of Medicine, New York, NY
| | - Rubiahna Vaughn
- Department of Psychiatry, New York University, Grossman School of Medicine, New York, NY; Department of Psychiatry, Montefiore Medical Center - Einstein Division, Albert Einstein College of Medicine, Bronx, NY
| | - Allison B Deutch
- Department of Psychiatry, New York University, Grossman School of Medicine, New York, NY
| | - Aviva Caroff
- Department of Psychiatry, New York University, Grossman School of Medicine, New York, NY
| | - Sharon Madanes
- Department of Psychiatry, New York University, Grossman School of Medicine, New York, NY
| | - Marra G Ackerman
- Department of Psychiatry, New York University, Grossman School of Medicine, New York, NY
| | - Crystal Lewis
- Department of Psychiatry, New York University, Grossman School of Medicine, New York, NY
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Appel JM. Anything You Do Not Say Can Be Used against You: Volitional Refusal to Engage in Decisional Capacity Assessment. THE JOURNAL OF CLINICAL ETHICS 2023; 34:204-210. [PMID: 37229737 DOI: 10.1086/725049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
AbstractThe most widely accepted model of decisional capacity assessment requires that a patient communicate a clear and consistent choice to the evaluator. This approach works effectively when patients prove unable to express a choice owing to physical, psychological, or cognitive limitations. In contrast, the approach raises ethics concerns when applied to patients who volitionally refuse to communicate a choice. This article examines the ethical issues that arise in such cases and offers a rubric for addressing decisional capacity under such circumstances.
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