As a doctor, I am tasked with making difficult clinical decisions – I use my professional expertise to gather information and apply critical thinking to determine the best plan of action. At the heart of this often complex process lies the doctor-patient relationship.

In liaison psychiatry, where we work at the interface between physical and mental health, our hospital colleagues will often call us to help them determine if a patient has “capacity” to make a treatment decision.

The way we approach this in England and Wales is set out for us in the Mental Capacity Act which aims to protect and empower those that might lack the capacity to make certain decisions. It advises that an individual has capacity to make a decision if they are able to demonstrate that they can understand the relevant information, retain this information for long enough to weigh up the different options, reach a decision and communicate it.

The concept of capacity is inextricably intertwined with the notion of consent. In clinical life, “informed consent” refers to the duty that health professionals have to provide patients with enough information about the potential benefits and risks associated with different treatment options. Knowledge informs decisions.

Regardless of capacity, most of the patients I see will have opinions about their care. These opinions are often held and expressed very strongly. You have to have a very compelling reason to override a patient’s autonomy and this should always be done by using the relevant legal framework, not only for the protection of the patient but also the professionals involved. That said, it’s important to bear in mind that just because the law allows you to do something, it doesn’t mean that it is necessarily the right thing to do.

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I am much more likely to be contacted to assess capacity if someone is refusing the treatment on offer. Health professionals can have a paternalistic attitude of “there must be something wrong with this patient if they’re disagreeing with my expert opinion”. Part of my role can be to advocate for a patient making a seemingly unwise decision while acknowledging that it can be hard for health professionals to accept that somebody doesn’t want the “best” treatment on offer. After all, most of us signed up to this line of work out of a desire to help people, so when our offer of help is rejected it can feel professionally bruising.

Time and again, I am humbled by the extremely difficult decisions that patients and their loved ones have to make. All too often, there is no clear good option and the decision-making process can end up feeling like a particularly cruel version of the game “Would You Rather?”.

Would you rather deal with the psychological fallout of having a late termination or continue with your pregnancy and have a severely disabled child?

Would you rather support the decision to detain your partner under the Mental Health Act, which you know will cause them enormous distress, or respect their wishes, which you know could result in their suicide?

Would you rather that we administer nutrition via a nasogastric tube against your will and keep you alive or respect your desire not to eat and allow your anorexia nervosa-induced starvation to kill you?

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You’ll be glad to know that I don’t frame these choices quite so bluntly when I’m talking to patients and their families, but these extremely challenging clinical conversations do boil down to such stark choices.

I am sometimes asked, “What would you do if you were me, doctor?” In some ways this is a totally reasonable question given my relevant expertise – indeed, I’ve asked this question myself when I’ve been a patient.

But the reality is, these decisions are often deeply personal and try as I might I can never really know what it’s like to walk in someone else’s shoes and what the impact of their decision will be. I am also aware of the fact that as a doctor I deal in probabilities rather than certainties – I can’t provide any guarantees about what will happen, I can only share my clinical experience and my knowledge of the evidence.

For doctors working in the NHS, there is no shortage of policies, protocols, guidelines, algorithms and legislation designed to support us with our clinical decision-making. And yet, despite this and the many years of study and clinical practice, it is sometimes hard to know what the best next step is. At times like this, I keep in mind the advice that a more senior psychiatrist once gave me when I was feeling a bit lost: “When in doubt, pick the kindest option.” Wise words that to this day hold true for both personal and professional life.

Mariam Alexander is an NHS consultant liaison psychiatrist



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