A 56-year-old woman with a history of schizophrenia is hospitalized for right upper quadrant abdominal pain and diagnosed with cholecystitis. She is initially treated with antibiotics, and a scheduled cholecystectomy is planned. On day 2 of hospitalization, the patient reports that she feels much better. The patient doesn't want surgery and prefers to go home on oral antibiotics. She says, "I know that God is on my side and will take care of me." The patient lives in a group home and takes risperidone daily at her day treatment program. On examination, the patient is alert and oriented to person, place, and time. She reports hearing voices several times a day for many years, but they don't bother her as much as they used to. The patient has no suicidal ideation. Which of the following is the best next step in management of this patient?

Question

A 56-year-old woman with a history of schizophrenia is hospitalized for right upper quadrant abdominal pain and diagnosed with cholecystitis.  She is initially treated with antibiotics, and a scheduled cholecystectomy is planned.  On day 2 of hospitalization, the patient reports that she feels much better.  The patient doesn't want surgery and prefers to go home on oral antibiotics.  She says, "I know that God is on my side and will take care of me."  The patient lives in a group home and takes risperidone daily at her day treatment program.  On examination, the patient is alert and oriented to person, place, and time.  She reports hearing voices several times a day for many years, but they don't bother her as much as they used to.  The patient has no suicidal ideation.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec160b_3657_fcca_9249_3524d77b72e6_MD0001_00 Although patients with schizophrenia are at higher risk for cognitive difficulties that may result in impaired decision-making, a diagnosis of schizophrenia, by itself, is not a reason to assume the patient lacks decision-making capacity. This patient is alert, oriented, and able to understand and communicate a preferred treatment option (ie, she doesn't want surgery and prefers to go home on antibiotics). It is less clear to what extent she appreciates the consequences of her decision and whether current psychotic symptoms (eg, delusions, hallucinations) may be influencing her ability to weigh the risks and benefits rationally. When there is a possibility that psychiatric symptoms are impairing cognition, the next step is to perform a formal, decision-specific capacity assessment. The patient's ability to understand and weigh the risks of going home should be explored. Delusions or hallucinations, if present, are only relevant to the assessment if they interfere with the patient's decision-making (eg, if the patient was hearing and following command hallucinations). If she meets the 4 requisite criteria for decisional capacity, her decision should be respected. (Choice A) This patient appears to be psychiatrically stable on her current dose of risperidone, and there is no indication that she is experiencing an acute exacerbation of psychotic symptoms that would require a dosage increase. (Choice C) A patient cannot be hospitalized involuntarily on the basis of a diagnosis of schizophrenia. Criteria for involuntary hospitalization include dangerousness to self or others or grave disability/inability to care for self. (Choice D) A next of kin can act only as surrogate decision-maker if the patient is assessed as lacking decision-making capacity. (Choice E) The right to refuse treatment requires intact decision-making capacity. A decision-specific capacity assessment should be performed before accepting the patient's refusal of surgery. Educational objective: A diagnosis of schizophrenia, by itself, is not a reason to assume a patient lacks decision-making capacity. A capacity assessment should be performed prior to treatment and includes the ability to understand information, appreciate potential consequences, communicate a choice, and offer a rationale. __________ References: Assessment of healthcare decision-making capacity. (http://www.ncbi.nlm.nih.gov/pubmed/27551024)

A 56-Year-Old Woman with a History of Schizophrenia Is Hospitalized