Racial Disparities in Psychiatric Decisional Capacity Consultations
Abstract
Objective:
In this study, the authors examined potential disparities and biases in the placement and outcomes of decisional capacity evaluations across races, controlling for patient characteristics.
Methods:
The authors reviewed 181 patient decisional capacity consultations requested for the consultation-liaison psychiatry service at a tertiary care medical center from 2018 to 2019. The racial distribution of patients in these consultations was compared with the racial distribution of hospital inpatient admissions from 2018 to 2019. The authors analyzed patient outcomes by using logistic regression that controlled for race, gender, age, education, primary insurance, type of capacity assessment, and psychiatric diagnosis.
Results:
Decisional capacity consultations were placed disproportionately for Black (43% of consultations vs. 18% of total admissions) and Hispanic patients (26% of consultations vs. 21% of admissions) compared with White and Asian patients. Among 130 patients with a capacity determination, 95 (53% of total sample) were determined not to have capacity, an outcome that did not differ by race but was more likely to occur among patients diagnosed as having delirium. Sixty-seven patients with no capacity (37% of total sample) experienced a change in treatment, an outcome that was less likely to occur among Hispanic patients in the univariable analysis.
Conclusions:
Significant racial disparities were observed during the placement of a decisional capacity consultation. These findings reveal the potential biases introduced with both the initial challenge to a patient’s capacity and the subsequent outcomes of the consultation. As such, the balance of risk versus benefit or utility of these consultations in certain populations must be carefully considered.
HIGHLIGHTS
•
In this study, the authors examined whether racial disparities were present in the placement and outcomes of decisional capacity evaluations.
•
Significant racial disparities may exist during requests for decisional capacity consultations, which occur disproportionately with Black and Hispanic patients compared with White and Asian patients.
•
Psychiatrists should acknowledge disparate frequencies and impacts of decisional capacity assessments, which can negatively affect therapeutic relationships among patients, families, and care teams.
Patients have the presumed right to make decisions regarding their health care through the process of informed consent (1, 2). When patients may be unable to consider their options or appear to be making health decisions that are not consistent with their values and preferences, the physician has the unique ability, and possibly the responsibility, to further assess their decisional capacity (hereafter, “capacity”). This sensitive situation is one of the most common interfaces between primary consulting medical teams and consultation-liaison (CL) psychiatry services in the hospital setting, with the psychiatric consultant often called on to help conduct the medical evaluation of a patient’s capacity. Given that studies have estimated that 26%–40% of all medical inpatients do not possess capacity, it is no surprise that up to one-quarter of inpatient psychiatry consultations are related to this concern (3–5).
Capacity assessments, although intended in theory to protect patients’ interests, also inherently challenge patient autonomy. Thus, careful consideration of approaches to conducting such evaluations is required. Even in cases in which patients are ultimately determined to have decision-making capacity, the assessment process itself casts doubt on and interrupts their spontaneous ability to act on their own wishes. Given the critical implications of capacity assessment, many hospitals have developed systematic protocols for such determinations. Grisso and Appelbaum (6) laid out four criteria for determining capacity: the patient’s ability to communicate a choice, to understand the relevant information, to appreciate a situation and its consequences, and to reason rationally.
Although Grisso and Appelbaum’s (6) criteria are now widely used and implemented, significant variability remains in the quality and outcomes of capacity determinations. Capacity assessments are often inadequately performed, especially when completed by primary care providers rather than by consultation psychiatrists (7). A study that used standardized patient scenarios found that only 33% of experienced CL psychiatrists applying these criteria came to the same conclusion (8). A physician’s personal values can significantly contribute to the outcomes of capacity evaluations (9). In this study, we examined potential disparities and biases, by race-ethnicity, in the placement and outcomes of capacity evaluations.
Although this article focuses on the association between race and health care outcomes, it is important to consider racial disparities within a broader social context. The terms “systemic racism” and “structural racism” describe the widespread and entrenched nature of racial-ethnic biases beyond explicit individual prejudice. Whereas the term “systemic” pertains to the ways in which race is enmeshed within broader social constructs, the term “structural” alludes to the design of systems, processes, and policies that engender disparities within specific outcomes (10, 11).
Although racial-ethnic disparities in health care have been discussed as evidence of systemic bias, the medical literature has only just begun to interrogate the systems and processes that give rise to such disparities (12). Given the persistence of such disparities, it is no longer sufficient to merely acknowledge examples of explicit institutional racism, such as the now infamous Tuskegee syphilis study, or simply condemn explicit individual biases, such as the belief of many physicians that Black patients feel less pain (13, 14). Clinical outcomes that are racially disparate must be identified as symptoms of additional implicit bias, and the relevant clinical methods and policies must be reexamined.
Psychiatry is far from exempt from such an examination, given its long and troubled relationship with race. As the American Psychiatric Association has acknowledged, purportedly scientific studies of mental “health” and illness were intentionally used to denigrate, institutionalize, and remove autonomy from marginalized populations (15). From explicit arguments about the mental abilities of non-White patients to disproportionate diagnoses of mental illnesses, particularly schizophrenia, among the Black population, psychiatrists have consistently been relied on to legitimize racial discrimination (16). Given this historical medical oppression of racial-ethnic minority groups, coupled with documented negative societal attitudes toward their education, intelligence, and decision-making ability, hospital-based physicians’ assessment of capacity warrants significant scrutiny as a structural process highly vulnerable to implicit biases.
Prior work has called on psychiatrists to incorporate race and other social determinants of health into capacity assessments (17). However, no study has assessed potential racial disparities in capacity consultations. In this article, we examined at which points racial bias may occur during the process of assessing capacity.
Methods
We examined CL psychiatric capacity consultations placed by medical services for patients hospitalized at an urban tertiary care medical center in the United States over a 2-year period (January 2018–December 2019), totaling 181 evaluations. Data were collected via retrospective chart review of patient medical records, which contained demographic information, medical and surgical notes, and CL psychiatry notes. The CL psychiatry notes contained a standardized template with basic patient information (e.g., age and gender), race-ethnicity (with template choices including “White,” “Black,” “Hispanic,” “Asian,” or “other”), and a primary DSM-5 diagnosis. Capacity determinations were performed by psychiatry residents or CL fellows under the supervision of a board-certified CL attending psychiatrist. The assessments were conducted with Grisso and Appelbaum’s (6) framework for capacity determinations but without standardized instruments. The Epic SlicerDicer medical record self-service tool was used to determine the racial-ethnic distribution of total hospital admissions to the medical center’s inpatient units from 2018 to 2019. Patients classified as “other” race-ethnicity (3% of capacity consultations [N=5], 8% of total admissions [N=5,347]) were excluded from the analysis. Demographic information for the consulting physicians was unavailable and not included in the analysis. Demographic information for the CL psychiatrists was not included because of the consultation service’s small size.
This study contained four patient capacity outcomes. First, a “capacity consultation” was present for all 181 patients in this study and occurred when a provider documented a capacity consultation request in the medical record. Second, a “capacity determination” was identified for patients in this study only when a CL psychiatrist documented a capacity determination (i.e., capacity vs. no capacity) in the medical record. This method therefore excluded consultations in which a CL psychiatrist found no cause to question capacity or to formally document a determination after speaking with the primary medical team or after evaluating the patient. In these cases, the capacity determination was “deferred,” or the entire consultation question was reframed into a different psychiatric issue. Third, “no capacity” was identified when a CL psychiatrist documented that the patient had impaired capacity within the specific hospital context. Fourth, “change in treatment” occurred when a CL psychiatrist documented that the patient did not have capacity and when a chart review found that the patient’s hospital treatment changed because of the consultation and subsequent capacity determination.
We assumed that the most favorable capacity consultation is one that is actionable. An actionable capacity consultation includes a completed capacity determination and, if the patient is found to have no capacity, a resultant change in treatment. For example, a patient refusing antibiotics was determined to have delirium and no capacity to refuse antibiotics and, because of the consultation, ultimately received treatment. We assumed that a less favorable capacity consultation is one that is nonactionable. Nonactionable consultations include those that are deferred or reframed or those that include a completed determination of no capacity but no resultant change in treatment. Consultations are also framed as favorable or less favorable in relation to the harm-to-benefit ratio for the patient. Harm reflects an intrusion on the patient’s spontaneous ability to make choices, and benefit represents a change in the treatment course that prevents (via incapacitation) the patient from making a choice.
In this study, we examined several independent predictor variables, with a primary focus on potential differences in the study outcomes by race-ethnicity. Additional variables included gender, age, education, primary insurance, type of decisional capacity assessment (categorized into leave against medical advice, disposition, diagnosis, treatment, legal, or multiple), and type of primary DSM-5 diagnosis as made by a CL psychiatrist. DSM-5 diagnoses were clustered into the following categories: psychological factors affecting other medical condition, adjustment, or personality disorder; bipolar, depressive, or anxiety disorder; schizophrenia spectrum or other psychotic disorder; substance use disorder; neurocognitive disorder; or delirium. Major neurocognitive disorders and delirium are strongly associated with impaired capacity, particularly among those with advanced age (18, 19).
A chi-square goodness-of-fit test was used to examine whether the racial-ethnic distribution of patients with a capacity consultation reflected the racial-ethnic distribution of total admitted patients. Univariable and multivariable logistic regressions were used to examine potential differences in patient capacity outcomes by independent predictor variables. Data were analyzed with Stata, version 15. This study was approved by the institutional review board at the participating institution.
Results
In this study, we examined the racial-ethnic distribution of patients with capacity consultations versus the distribution of total patient admissions to the same inpatient units from 2018 to 2019 (Table 1). Capacity consultation requests were placed disproportionately for Black patients, who represented 43% of capacity consultations but only 18% of total inpatient admissions. Hispanic patients represented 26% of capacity consultations and 21% of admissions. Conversely, White patients represented only 28% of capacity consultations but 53% of admissions, and Asian patients represented 3% of capacity consultations but 9% of admissions. A chi-square goodness-of-fit test indicated that the racial-ethnic distribution of capacity consultations versus total admissions was significantly different (χ2=86.78, df=3, N=176, p<0.001).
| Capacity consultations (N=176)a | Total inpatient admissions (N=60,707) | |||
|---|---|---|---|---|
| Patient race-ethnicity | N | % | N | % |
| White | 49 | 28 | 32,212 | 53 |
| Black | 75 | 43 | 10,827 | 18 |
| Hispanic | 46 | 26 | 12,448 | 21 |
| Asian | 6 | 3 | 5,220 | 9 |
a
Patients classified as “other” race-ethnicity (N=5) were excluded from analysis.
Patient characteristics stratified by race-ethnicity are examined in Table 2. Among the different races and ethnicities, the data indicated no significant difference in gender, age, primary insurance, type of capacity assessment, and type of primary DSM-5 diagnosis. About half of all consultations were for neurocognitive disorder or delirium, including all consultations with Asian patients, although the sample size was only six. Black and Hispanic patients in the sample were found to have lower educational attainment than White patients (p<0.01). However, the educational status of about half of all patients was unknown.
| Race-ethnicity | |||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| All patients (N=181) | Black (N=75) | White (N=49) | Hispanic (N=46) | Asian (N=6) | Other (N=5) | ||||||||
| Characteristic | N | % | N | % | N | % | N | % | N | % | N | % | pb |
| Gender | .316 | ||||||||||||
| Cisgender man | 94 | 52 | 37 | 49 | 23 | 47 | 25 | 54 | 4 | 67 | 5 | 100 | |
| Cisgender woman | 84 | 46 | 37 | 49 | 26 | 53 | 19 | 41 | 2 | 33 | 0 | — | |
| Transgender woman | 3 | 2 | 1 | 1 | 0 | — | 2 | 4 | 0 | — | 0 | — | |
| Age in years | .78 | ||||||||||||
| <65 | 92 | 51 | 42 | 56 | 22 | 45 | 23 | 50 | 3 | 50 | 2 | 40 | |
| ≥65 | 89 | 49 | 33 | 44 | 27 | 55 | 23 | 50 | 3 | 50 | 3 | 60 | |
| Education | <.01 | ||||||||||||
| Unknown | 83 | 46 | 38 | 51 | 19 | 39 | 18 | 39 | 4 | 67 | 4 | 80 | |
| Less than high school diploma | 22 | 12 | 9 | 12 | 0 | — | 12 | 26 | 0 | — | 1 | 20 | |
| High school diploma | 44 | 24 | 16 | 21 | 13 | 27 | 15 | 33 | 0 | — | 0 | — | |
| Collegec | 32 | 18 | 12 | 16 | 17 | 35 | 1 | 2 | 2 | 33 | 0 | — | |
| Primary insurance | .33 | ||||||||||||
| Uninsured | 5 | 3 | 3 | 4 | 1 | 2 | 1 | 2 | 0 | — | 0 | — | |
| Medicaid | 57 | 31 | 26 | 35 | 9 | 18 | 17 | 37 | 2 | 33 | 3 | 60 | |
| Medicare | 102 | 56 | 38 | 51 | 31 | 63 | 27 | 59 | 4 | 67 | 2 | 40 | |
| Work or commercial | 17 | 9 | 8 | 11 | 8 | 16 | 1 | 2 | 0 | — | 0 | — | |
| Capacity assessment | .09 | ||||||||||||
| Leave AMA | 46 | 25 | 19 | 25 | 15 | 31 | 10 | 22 | 2 | 33 | 0 | — | |
| Disposition | 37 | 20 | 13 | 17 | 8 | 16 | 14 | 30 | 2 | 33 | 0 | — | |
| Diagnosis | 17 | 9 | 12 | 16 | 3 | 6 | 2 | 4 | 0 | — | 0 | — | |
| Treatment | 55 | 30 | 20 | 27 | 15 | 31 | 16 | 35 | 1 | 17 | 3 | 60 | |
| Legal | 10 | 6 | 1 | 1 | 4 | 8 | 4 | 9 | 0 | — | 1 | 20 | |
| Multiple | 16 | 9 | 10 | 13 | 4 | 8 | 0 | — | 1 | 17 | 1 | 20 | |
| Primary psychiatric diagnosis | .43 | ||||||||||||
| Psychological, adjustment, or personality | 40 | 22 | 12 | 16 | 17 | 35 | 11 | 24 | 0 | — | 0 | — | |
| Bipolar, depressive, or anxiety | 12 | 7 | 6 | 8 | 4 | 8 | 2 | 4 | 0 | — | 0 | — | |
| Schizophrenia spectrum or other psychotic | 16 | 9 | 10 | 13 | 2 | 4 | 3 | 7 | 0 | — | 1 | 20 | |
| Substance use | 19 | 10 | 11 | 15 | 2 | 4 | 6 | 13 | 0 | — | 0 | — | |
| Neurocognitive disorder | 45 | 25 | 17 | 23 | 10 | 20 | 12 | 26 | 4 | 67 | 2 | 40 | |
| Delirium | 49 | 27 | 19 | 25 | 14 | 29 | 12 | 26 | 2 | 33 | 2 | 40 | |
a
AMA, against medical advice.
b
From Pearson chi-square tests.
c
Associate’s, bachelor’s, master’s, or doctoral degree.
Figure 1 depicts this study’s four patient decisional capacity outcomes (capacity consultation, capacity determination, no capacity, and change in treatment) arranged in a capacity cascade. The cascade depicts the decreasing number of patients along each step of the outcome continuum and ends in the number and percentage of patients with a change in treatment, a presumed favorable outcome of the consultation. Among the total study population of 181 patients of all races with a documented capacity consultation, 130 individuals (72%) had a capacity determination completed by a CL psychiatrist, whereas the remaining 51 individuals (28%) had deferred or reframed capacity consultations. Ninety-five individuals (53%) were determined to have no capacity, whereas 35 individuals (19%) were determined to have capacity. Sixty-seven individuals (37%) had a change in treatment after being found to not have capacity, whereas the remaining 28 individuals (16%) did not have a change in treatment (figures depicting the outcomes among Black, White, Hispanic, and Asian subpopulations are available in the online supplement to this article). Although capacity consultations requested by the consulting medical teams were disproportionately placed for Black and Hispanic patients (Table 1), the figures in the online supplement and subsequent logistic regression analyses indicated that the remaining three outcomes in the cascade were relatively similar among each racial-ethnic category.
We ascertained the reasons why no change in treatment occurred for patients with impaired capacity, a presumed unfavorable occurrence that was nevertheless an outcome for 28 patients (out of 95 with no capacity, or 29%). Hispanic patients with no capacity were most likely to not receive a change in treatment (12 out of 25 with no capacity, or 48%). This outcome occurred among White and Black patients at lower frequencies (30% [N=8 of 27] and 23% [N=8 of 35], respectively) compared with Hispanic patients, and this outcome did not occur among Asian patients. In 16 cases of impaired capacity, the primary consulting medical team ultimately followed a treatment plan consistent with the patient’s initial medical decision. In some of these cases, the record implied that a refused intervention could be deferred to outpatient care. For seven patients with impaired capacity, the medical record specifically indicated that the treatment course remained unchanged because the medical intervention in question was no longer indicated given the patient’s poor prognosis, the patient’s clinical improvement, or the risk of the procedure. For five patients with impaired capacity, the patient’s initial decision was supported by their involved substitute decision maker, rendering the consulting medical team incapable of implementing the recommended treatment.
We performed a series of logistic regression analyses to determine whether patient-level characteristics were statistically associated with increased odds of capacity outcomes: capacity consultation (vs. no capacity determination), no capacity (vs. having capacity), and no change in treatment (vs. change). The odds of a CL psychiatrist completing the patient’s capacity consultation (vs. deferring or reframing the consultation) were not significantly associated with any of the study variables, including race-ethnicity, gender, age, education, primary insurance, type of capacity assessment, or DSM-5 diagnosis (data not shown). The odds of a CL psychiatrist concluding that an individual had no capacity were not significantly associated with most of the variables, including race. However, patients with delirium were more likely to have no capacity compared with patients with psychological, adjustment, or personality disorder diagnoses in the univariable analysis (odds ratio [OR]= 5.98, 95% confidence interval [CI]=1.75–20.36, p<0.01). After controlling for race, age, and education, we found that patients with a delirium diagnosis continued to be more likely to have no capacity (OR=5.68, 95% CI=1.56–20.52, p=0.01) (Table 3).
| Univariable | Multivariable | |||||
|---|---|---|---|---|---|---|
| Variable | OR | 95% CI | p | OR | 95% CI | p |
| Race (reference: Black) | ||||||
| White | 1.49 | .57–3.90 | .41 | 1.63 | .56–4.77 | .37 |
| Hispanic | 1.16 | .47–2.91 | .75 | 1.48 | .53–4.14 | .42 |
| Asian | 5.27 | .27–100.83 | .27 | 4.06 | .18–91.06 | .38 |
| Other | 3.35 | .16–68.60 | .43 | 1.94 | .08–46.76 | .68 |
| Age (reference: <65) | ||||||
| ≥65 | 1.87 | .86–4.06 | .12 | 1.05 | .42–2.59 | .92 |
| Education (reference: less than high school diploma) | ||||||
| High school diploma | 1.34 | .40–4.49 | .63 | 1.42 | .36–5.56 | .61 |
| Collegea | 1.41 | .39–5.12 | .61 | 1.40 | .31–6.44 | .66 |
| Unknown | 3.28 | .97–11.08 | .06 | 3.59 | .91–14.13 | .07 |
| Psychiatric diagnosis (reference: psychological, adjustment, or personality) | ||||||
| Bipolar, depressive, or anxiety | 2.27 | .31–16.60 | .42 | 2.44 | .33–18.01 | .38 |
| Schizophrenia spectrum or other psychotic | 1.26 | .32–5.02 | .74 | 1.04 | .23–4.68 | .96 |
| Substance use | .64 | .17–2.48 | .52 | .60 | .14–2.52 | .49 |
| Neurocognitive disorder | 2.54 | .88–7.34 | .09 | 2.00 | .62–6.44 | .24 |
| Delirium | 5.98 | 1.75–20.36 | <.01 | 5.68 | 1.56–20.52 | .01 |
a
Associate’s, bachelor’s, master’s, or doctoral degree.
Hispanic patients with no capacity were more likely not to experience a change in treatment (the presumed less favorable outcome) compared with Black patients in the univariable analysis (OR=3.10, 95% CI=1.05–9.19, p=0.04). This association was no longer significant after controlling for psychiatric diagnosis, age, and education. Patients with a high school diploma were less likely to have no change in treatment compared with those without one in the multivariable analysis (OR=0.13, 95% CI=0.02–0.88, p=0.04) (Table 4). Hispanic patients had the lowest levels of education (Table 2).
| Univariable | Multivariable | |||||
|---|---|---|---|---|---|---|
| Variable | OR | 95% CI | p | OR | 95% CI | p |
| Race (reference: Black) | ||||||
| White | 1.29 | .41–4.03 | .66 | 1.24 | .35–4.40 | .74 |
| Hispanic | 3.10 | 1.05–9.19 | .04 | 2.81 | .85–9.29 | .09 |
| Asian | .30 | .02–6.09 | .44 | .24 | .01–5.10 | .36 |
| Other | 2.02 | .23–17.52 | .53 | 2.90 | .29–28.57 | .36 |
| Age (reference: <65) | ||||||
| ≥65 | .88 | .37–2.10 | .77 | .50 | .17–1.46 | .20 |
| Education (reference: less than high school diploma) | ||||||
| High school diploma | .29 | .06–1.33 | .11 | .13 | .02–.88 | .04 |
| Collegea | .36 | .07–1.78 | .21 | .25 | .03–1.98 | .19 |
| Unknown | .31 | .08–1.24 | .10 | .13 | .05–1.46 | .13 |
| Psychiatric diagnosis (reference: psychological, adjustment, or personality) | ||||||
| Bipolar, depressive, or anxiety | 2.96 | .35–25.09 | .20 | 3.86 | .44–33.82 | .22 |
| Schizophrenia spectrum or other psychotic | .29 | .04–2.20 | .23 | .16 | .02–1.45 | .10 |
| Substance use | .12 | .01–2.43 | .17 | .06 | .00–1.45 | .08 |
| Neurocognitive disorder | .53 | .15–1.83 | .32 | .78 | .21–3.28 | .78 |
| Delirium | .45 | .14–1.52 | .20 | .21 | .11–1.65 | .22 |
a
Associate’s, bachelor’s, master’s, or doctoral degree.
Discussion
Significant racial disparities may exist within decisional capacity consultation placements. Capacity assessments appear subject to bias from the beginning of the process. Black patients, and to a less stark degree Hispanic patients, underwent capacity assessments requested by primary consulting medical teams at a disproportionately high rate in relation to the overall racial demographic composition of admitted hospital inpatients (Table 1). When challenges to autonomy occur at such a disproportionate rate, a consulting provider’s introduction of a capacity assessment into a patient’s clinical picture has the potential for harm. It raises questions regarding the patient’s decision-making autonomy and capabilities, with significant implications for the perpetuation and worsening of the patient’s vulnerability in the health care system.
In this study, we tracked the outcomes of consultations with a unique cascade format (Figure 1, online supplement), which illustrated that most capacity assessments were ultimately not clinically relevant or actionable. Only 37% of patients (N=67) were found to lack capacity and experienced a change in hospital treatment, whereas the rest either had no completed consultation or experienced no impact on treatment despite a capacity determination. For 28% of patients (N=51), consultations were deferred or reframed because the capacity question was not actionable. When the question was reframed, the consultant attempted to reconcile the patient’s and treatment team’s needs while preserving the patient’s capacity. Another study examining patients who threatened to leave against medical advice (a common reason for capacity consultations, including 25% of this sample) highlighted the efficacy of unveiling and addressing hospitalized patients’ fear, anger, transference reactions, clashes with hospital staff, and other issues instead of framing the threats as a capacity problem (20).
Aside from the greater proportion of consultations observed among Black and Hispanic patients relative to total inpatient admissions, the race-specific capacity cascades and logistic regression analyses did not significantly differ or reveal biases within the CL psychiatric assessments. Black and Hispanic patients in this study had lower educational attainment compared with White patients. Others have studied the impact of lower educational attainment on capacity and informed-consent processes (21, 22). This study suggests that patients from racial-ethnic minority groups may disproportionately face capacity challenges in hospital-based psychiatry consultations as an outcome of ethnic and racial disparities in education. A presumed unfavorable outcome from a capacity assessment—having one’s autonomy revoked by an assessment yet subsequently not receiving treatment recommended by the doctors—was most common in this study among Hispanic patients and among those with less than a high school education. After a patient is determined to lack capacity, the providers must take challenging additional steps to coordinate with the persistently nonconsenting patient and surrogate decision maker about the proposed treatment. Oftentimes, this process breaks down, and in these steps lies further potential for discrimination.
This study has several limitations. The sample size was small and potentially lacked the power to detect differences in capacity assessment outcomes by race-ethnicity. Furthermore, because the sample was taken from a single hospital, the results possibly lack generalizability. Data in the chart review did not include potentially relevant information, such as the primary spoken language (e.g., non–English-speaking Hispanic patients), as well as details regarding patients’ identified races or ethnicities (including multiracial) beyond the broad categories included in chart templates. Data from the Epic SlicerDicer tool, including race-ethnicity, are difficult to validate and are of generally poorer quality than the demographic data from the CL psychiatry notes. Finally, race-ethnicity and other characteristics of the consulting medical providers and of the CL psychiatrists, which could have influenced the outcomes, were not captured.
Conclusions
Racial-ethnic disparities are widespread in the U.S. health care system and have been noted in psychiatric diagnoses and treatments (23). It is not surprising that racial disparities would be observed within capacity assessments. Ideally, because consultations for capacity assessment impose a burden on patients, such assessments would be requested objectively and without bias and only when necessary to guide clinical care. In practice, our findings indicate that patients from certain racial-ethnic groups are subject to such assessments with greater frequency than are those from different racial-ethnic groups. Given the predominantly White and Asian racial-ethnic makeup of the medical profession in the United States (24), and data showing that physicians’ personal values play a role in the outcome of capacity evaluations, many avenues exist for the introduction of bias in the treatment of these patients. Providers and institutions should take additional steps to protect patients from such bias.
Capacity challenges are not benign tools that merely facilitate assessment. Rather, they are significant interventions that can subject patients to psychological distress. The threat of losing autonomy can prove burdensome to individuals from racial-ethnic communities who already have reason to distrust the medical establishment. Such assessments, especially when they are nonactionable, can jeopardize therapeutic relationships and strain alliances among patients, families, and care teams. Psychiatrists must acknowledge the disparate impact of such assessments, even when they might be imposed equitably. Capacity challenges that reflect underlying, systemic racial-ethnic biases in health care only exacerbate existing disparities.
Supplementary Material
File (appi.ps.202100685.ds001.pdf)
- View/Download
- 299.86 KB
References
1.
Schloendorff v Society of New York Hospital, 211 NY 125, 129–130 (1914)
2.
Informed Consent. Chicago, American Medical Association, 2021. https://www.ama-assn.org/delivering-care/ethics/informed-consent. Accessed May 6, 2022
3.
Sessums LL, Zembrzuska H, Jackson JL: Does this patient have medical decision-making capacity? JAMA 2011; 306:420–427
4.
Sorrentino R: Performing capacity evaluations: what’s expected from your consult. Curr Psychiatr 2014; 13:41–44
5.
Marson DC, McInturff B, Hawkins L, et al: Consistency of physician judgments of capacity to consent in mild Alzheimer’s disease. J Am Geriatr Soc 1997; 45:453–457
6.
Grisso T, Appelbaum PS: Assessing Competence to Consent to Treatment: A Guide for Physicians and Other Health Professionals. New York, Oxford University Press, 1998
7.
Chan CY, Yong SW, Mhaisalkar AS, et al: Audit of mental capacity assessment by primary care physicians versus consultation-liaison psychiatrists. East Asian Arch Psychiatry 2018; 28:95–100
8.
Armontrout J, Gitlin D, Gutheil T: Do consultation psychiatrists, forensic psychiatrists, psychiatry trainees, and health care lawyers differ in opinion on gray area decision-making capacity cases? A vignette-based survey. Psychosomatics 2016; 57:472–479
9.
Hermann H, Trachsel M, Biller-Andorno N: Physicians’ personal values in determining medical decision-making capacity: a survey study. J Med Ethics 2015; 41:739–744
10.
Bailey ZD, Krieger N, Agénor M, et al: Structural racism and health inequities in the USA: evidence and interventions. Lancet 2017; 389:1453–1463
11.
Metzl JM, Hansen H: Structural competency: theorizing a new medical engagement with stigma and inequality. Soc Sci Med 2014; 103:126–133
12.
Rosenblatt R, Lee H, Liapakis AM, et al: Equitable access to liver transplant: bridging the gaps in the social determinants of health. Hepatology 2021; 74:2808–2812
13.
Paul C, Brookes B: The rationalization of unethical research: revisionist accounts of the Tuskegee syphilis study and the New Zealand “unfortunate experiment”. Am J Public Health 2015; 105:e12–e19
14.
Hoffman KM, Trawalter S, Axt JR, et al: Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between Blacks and Whites. Proc Natl Acad Sci U S A 2016; 113:4296–4301
15.
Warner J: Psychiatry Confronts Its Racist Past, and Tries to Make Amends. New York Times, 2021. https://www.nytimes.com/2021/04/30/health/psychiatry-racism-black-americans.html. Accessed May 6, 2022
16.
Smith K: How Bigotry Created a Black Mental Health Crisis. Washington, DC, Washington Post, 2019. https://www.washingtonpost.com/outlook/2019/07/29/how-bigotry-created-black-mental-health-crisis. Accessed May 6, 2022
17.
Erickson BR, Pereira J, Bromley E, et al: A case for psychiatric leadership in dispositional capacity assessment. Psychiatr Serv 2022; 73:683–685
18.
Boettger S, Bergman M, Jenewein J, et al: Advanced age and decisional capacity: the effect of age on the ability to make health care decisions. Arch Gerontol Geriatr 2016; 66:211–217
19.
Amalraj S, Starkweather C, Nguyen C, et al: Health literacy, communication, and treatment decision-making in older cancer patients. Oncology 2009; 23:369–375
20.
Albert HD, Kornfeld DS: The threat to sign out against medical advice. Ann Intern Med 1973; 79:888–891
21.
McCaffery KJ, Smith SK, Wolf M: The challenge of shared decision making among patients with lower literacy: a framework for research and development. Med Decis Making 2010; 30:35–44
22.
Taub HA, Baker MT, Sturr JF: Informed consent for research. Effects of readability, patient age, and education. J Am Geriatr Soc 1986; 34:601–606
23.
Mental Health Disparities: Diverse Populations. Arlington, VA, American Psychiatric Association, 2017. https://www.psychiatry.org/psychiatrists/cultural-competency/education/mental-health-facts. Accessed May 6, 2022
24.
Diversity in Medicine: Facts and Figures 2019. Washington, DC, Association of American Medical Colleges, 2019. https://www.aamc.org/data-reports/workforce/interactive-data/figure-18-percentage-all-active-physicians-race/ethnicity-2018. Accessed July 27, 2022
Information & Authors
Information
Published In
History
Received: 3 December 2021
Revision received: 11 March 2022
Revision received: 21 April 2022
Accepted: 29 April 2022
Published online: 25 August 2022
Published in print: January 01, 2023
Keywords
Authors
Competing Interests
The authors report no financial relationships with commercial interests.
Funding Information
The authors represent clinicians from Black, Indigenous, and people of color (BIPOC) and non-BIPOC backgrounds. One of the BIPOC authors (Dr. Mirza) was an attending physician on the consultation-liaison psychiatry service during the study period and contributed to the decisional capacity assessments.
Metrics & Citations
Metrics
Citations
Export Citations
If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download.
For more information or tips please see 'Downloading to a citation manager' in the Help menu.
View Options
View options
PDF/EPUB
View PDF/EPUBLogin options
Already a subscriber? Access your subscription through your login credentials or your institution for full access to this article.
Personal login Institutional Login Open Athens loginNot a subscriber?
PsychiatryOnline subscription options offer access to the DSM-5-TR® library, books, journals, CME, and patient resources. This all-in-one virtual library provides psychiatrists and mental health professionals with key resources for diagnosis, treatment, research, and professional development.
Need more help? PsychiatryOnline Customer Service may be reached by emailing [email protected] or by calling 800-368-5777 (in the U.S.) or 703-907-7322 (outside the U.S.).