Decision Making Capacity

In the 1914 case of Schloendorff versus the Society of New York Hospital, Justice Cardozo wrote, “every human being of adult years and sound mind has a right to determine what shall be done with his own body.” Determining a "sound mind," or decision making capacity is something that we do often in the emergency department. This makes many providers uncomfortable because it gives patients the ability to refuse our recommendations. This POTD is going to go over what defines capacity and how we can assess it. 

Capacity refers to the ability of a person to utilize information about their illness and proposed treatments to make a choice that aligns with their values. Determining capacity is often a clinical judgment typically made by a physician, whereas competence is a legal state determined by a judge. Assessing for capacity allows us to act in our patient’s best interest while respecting their autonomy. 

You can assess for capacity by determining if the patient has the ability to: 1. Communicate 2. Understand the information 3. Understand the situation 4. Manipulate the information presented and make a logical decision.

These points can be ascertained by asking the patient to recount their story, your recommendations, state what they do or don't want, and back their decision up with logic. 

It is important to note that capacity is defined around a specific medical decision; you should assess capacity with each new intervention or treatment proposed. In addition, capacity can be transient and exist along a continuum. So before you call up psych to help determine if your patient can refuse dialysis, go through these 4 points and see if you can determine decision making capacity yourself.

Thanks for reading!

Ariella

References: 

https://www.emrap.org/episode/november2014/decisionmaking

https://www.uptodate.com/contents/assessment-of-decision-making-capacity-in-adults

Ariella Cohen

M.D. Emergency Medicine

Maimonides Medical Center

Medical Abortions & Misoprostol Toxicity

Medical abortions can be done until 11 weeks of pregnancy and are 98% successful in terminating a pregnancy. They are popular because they are relatively safe and easy to administer. As of 2021, patients can get these medications via mail or pharmacy. 

Contraindications for medical abortions include ectopic pregnancies, pregnancy > 11 weeks, adrenal insufficiency, renal failure, liver failure, cardiac disease, and coagulopathy. 

Medical abortions are typically performed using Mifepristone and Misoprostol. Mifepristone blocks progesterone, preventing the pregnancy from progressing. Misoprostol, a synthetic prostaglandin E1, induces uterine cramping to help expel the pregnancy (think: misoprostol, like prostaglandin). Misoprostol should be taken 24-48 hours after mifepristone and patients should expect to have some bleeding but it should not exceed 2 pads/hr for 2 consecutive hours (think: rule of 2s). Patients are encouraged to take a repeat pregnancy test at 4 weeks or get an US to confirm termination after taking these medications.  

• Mifepristone dose: 200 mg PO

• Misoprostol dose: 800 mcg x1-2 buccally or transvaginally. 

  • If given buccally, the patient will place two 200 mcg pills in each cheek and let them dissolve.

Given the stigma and laws prohibiting safe abortions, many people are now seeking alternative means for abortions, such as medications they find on the internet. Some medications marketed as misoprostol are not regulated and contain other dangerous substances. 

Misoprostol toxicity is very rare, however, due to more limited access to these medications people are at increased risk for harmful side effects. Normal doses of misoprostol in safe abortions are 200-1000 mcg depending on the route. This may cause a slight fever, chills, cramping, nausea, vomiting, or diarrhea, but symptoms typically improve quickly. Toxic doses are in the 3-8 mg range; these patients may have severe GI issues, high fever, chills, severe myalgias with rhabdo, bradycardia, hypoxia, AMS, and hypotension. Doses as high as 12 mg may result in multisystem organ failure and death. Symptoms develop very quickly after ingestion as it is completely absorbed from the stomach in 90 mins. Treatment involves removing any tablets from the vaginal canal, rectum, maybe stomach, and supportive care/symptomatic management until symptoms resolve (usually 12 hours). 

Thanks for reading! 

Ariella

Resources:

https://www.who.int/news-room/fact-sheets/detail/abortion

https://www.emrap.org/episode/emrap2022july1/postabortion

https://www.uptodate.com/contents/first-trimester-pregnancy-termination-medication-abortion?search=medical%20abortion&source=search_result&selectedTitle=1~73&usage_type=default&display_rank=1

https://bmcwomenshealth.biomedcentral.com/articles/10.1186/s12905-022-01889-6

Graber, D. J., & Meier, K. H. (1991). Acute misoprostol toxicity. Annals of emergency medicine, 20(5), 549-551.

Henriques, A., Lourenço, A. V., Ribeirinho, A., Ferreira, H., & Graça, L. M. (2007). Maternal death related to misoprostol overdose. Obstetrics & Gynecology, 109(2), 489-490.

Pelvic Inflammatory Disease & Tubo Ovarian Abscess

Pelvic inflammatory disease (PID) is an infection of the upper reproductive tract, which includes the uterus, fallopian tubes, and ovaries. The most common pathogens are gonorrhea and/or chlamydia which begin as a cervical infection and become polymicrobial as they ascend. Symptoms may include fever, nausea, vomiting, malaise, abdominal pain, purulent vaginal discharge, or abnormal vaginal bleeding. Unilateral adnexal tenderness/fullness may indicate a developing tubo ovarian abscess (TOA), a complication of PID. 

A TOA is an inflammatory mass that involves the fallopian tube, ovary, and sometimes other adjacent pelvic organs (bladder, bowel). They may require aggressive medical and/or surgical therapy as a ruptured TOA can result in sepsis. Treatment ranges from antibiotics to laparoscopy. Some stable, non-ruptured TOAs can be treated with antibiotics alone. Suggested antibiotic regimens include: 

• CTX 1g qd + doxycycline 100mg q12 + metronidazole 500 mg q12

• Cefotetan 2g IV q12 + doxycycline 100mg q12

• Cefoxitin 2g IV q6 + doxycycline 100mg q12.

Studies suggest that abscesses =/> 7 cm have a higher likelihood of requiring surgical therapy (drainage or surgical removal). Therefore, it is appropriate to trial IV abx if the patient is hemodynamically stable, has adequate response to initial IV abx, and has imaging that shows that the abscess is < 7 cm. 

Diagnosis can be made via transvaginal US or CT A/P. Conventional teaching is that US is the preferred modality for imaging pelvic organs to assess for TOAs. However, recent studies have shown that CT has a higher sensitivity for diagnosing TOAs. Therefore, common practice is to start with US as it helps rule out other pathology, such as ovarian torsion, and is less expensive and less radiation for the patient. A positive US can help establish the diagnosis, however, a negative US does not exclude a TOA and a CT is often indicated. Ultimately, TOAs are a clinical diagnosis and are often diagnosed in the setting of pelvic mass in patients who meet the diagnostic criteria for PID. These patients should get an OBGYN consult and be started on IV abx. 

Thanks for reading!

Ariella

Resources: 

1. Fouks Y, Cohen A, Shapira U, et al. Surgical Intervention in Patients with Tubo-Ovarian Abscess: Clinical Predictors and a Simple Risk Score. J Minim Invasive Gynecol 2019; 26:535

2. Lee"DC,"et"al.)Sensitivity)of)ultrasound)for)the)diagnosis)of)tuboAovarian)abscess:)A)case)report)and) literature)review.))J(Emerg(Med."2010"May"11"

3. https://www.uptodate.com/contents/epidemiology-clinical-manifestations-and-diagnosis-of-tubo-ovarian-abscess?search=tuboovarian%20abscess&topicRef=16419&source=see_link

4. https://www.uptodate.com/contents/management-and-complications-of-tubo-ovarian-abscess?search=tuboovarian%20abscess&source=search_result&selectedTitle=1~21&usage_type=default&display_rank=1