A 24-year-old woman comes to the office accompanied by her caseworker. This is the first time that she has been seen in the office, and she appears mildly anxious. However, she quickly relaxes once the female physician enters the room. The caseworker reports that the patient would like to discuss contraceptive options as she has become sexually active with her boyfriend. Medical history is remarkable for moderate intellectual disability and surgical repair of a cardiac defect as an infant. The patient says, "I would like to go on birth control. I want a baby one day but not until I am married." The caseworker reports that the patient's mother, who was unable to attend the appointment, is extremely concerned about the patient's plan. The mother wants the patient to have a tubal ligation as she does not think her daughter would ever be able to care for a child. The patient becomes tearful and says, "My mom doesn't know what's best for me. I know I can be a good mom." The patient reports that she does not have a guardian, and the caseworker confirms that the patient is responsible for her own decision making. The caseworker provides additional information regarding the patient's level of functioning. She states that the patient lives in a group home and has a female roommate. The patient plans to move in with her boyfriend, who has been diagnosed with borderline intellectual functioning. The patient says, "My boyfriend is very nice and helps me a lot. When we live together we can do the shopping ourselves. He has his own job and works in the supermarket 3 days a week. His sister is very nice, too, and she visits him every week. She said that there is an injection I can have so that I don't get pregnant until we are married." The physician educates the patient regarding contraception in simple terms and reviews the various birth control options, including depot progesterone injections. The patient responds, "I don't know. Whatever you recommend, doctor." Which of the following would be the most appropriate response to this patient?

Question

A 24-year-old woman comes to the office accompanied by her caseworker.  This is the first time that she has been seen in the office, and she appears mildly anxious.  However, she quickly relaxes once the female physician enters the room.  The caseworker reports that the patient would like to discuss contraceptive options as she has become sexually active with her boyfriend.  Medical history is remarkable for moderate intellectual disability and surgical repair of a cardiac defect as an infant.  The patient says, "I would like to go on birth control.  I want a baby one day but not until I am married."  The caseworker reports that the patient's mother, who was unable to attend the appointment, is extremely concerned about the patient's plan.  The mother wants the patient to have a tubal ligation as she does not think her daughter would ever be able to care for a child.  The patient becomes tearful and says, "My mom doesn't know what's best for me.  I know I can be a good mom." The patient reports that she does not have a guardian, and the caseworker confirms that the patient is responsible for her own decision making.  The caseworker provides additional information regarding the patient's level of functioning.  She states that the patient lives in a group home and has a female roommate.  The patient plans to move in with her boyfriend, who has been diagnosed with borderline intellectual functioning.  The patient says, "My boyfriend is very nice and helps me a lot.  When we live together we can do the shopping ourselves.  He has his own job and works in the supermarket 3 days a week.  His sister is very nice, too, and she visits him every week.  She said that there is an injection I can have so that I don't get pregnant until we are married."  The physician educates the patient regarding contraception in simple terms and reviews the various birth control options, including depot progesterone injections.  The patient responds, "I don't know.  Whatever you recommend, doctor."  Which of the following would be the most appropriate response to this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c1ea_97c7_8f63_e7638fba1f59_MD0005_00 At age 18, a person with intellectual disability is presumed to be a competent adult with the ability to make health care decisions, including those related to reproductive health. However, given this patient's known cognitive impairment, her ability to make her own medical care decisions is in question. Therefore, the first step is for the physician to evaluate the patient's capacity to make an informed decision about using contraception at this time. There are four important criteria for assessing a patient's capacity: The patient's understanding of the options, appreciation of the possible consequences of a decision, ability to weigh the risks and benefits of a decision, and ability to communicate a decision based on these considerations. In this case, the patient's understanding of the options and consequences is unclear. The physician should ask the patient to repeat back what was discussed in order to assess if she has an understanding of the information presented. If her capacity is in question, the next step would be to consider filing for a guardianship application with the courts. (Choice A) The physician should first assess this patient's capacity to make this decision. (Choices B and E) The patient should be given educational materials and time to confer with others about her decision. However, this will not help the physician in determining if the patient has the capacity to make her own decision. (Choice D) A physician should not administer treatment to a patient who lacks the capacity to make decisions, even if the patient consents to the treatment. Educational objective: Adult patients with intellectual disability are allowed to make health care decisions for themselves, unless it is determined that they lack decision-making capacity and guardianship has been established. Physicians play a role in the assessment of capacity. References: Sexual and reproductive health care for women with intellectual disabilities: a primary care perspective (http://www.ncbi.nlm.nih.gov/pubmed/24455249)

A 24-Year-Old Woman Comes to the Office Accompanied by Her