Assessing Medical Decision Making Capacity

Transcription

1 Assessing Medical Decision Making Capacity Marc Zisselman M.D. Sheppard Pratt Health System Director Geriatric Service Line * I have no disclosures, conflicts of Interest relevant to this Presentation

2 Obtaining Informed Consent Required by law and medical ethics Appropriate information disclosure Balance between autonomy/beneficence

3 When to Assess Capacity Intrinsic aspect of every physician patient interaction Initiation of treatment Often Suboptimal -modalities to optimize capacity

4 Capacity and Competency Terms often used interchangeably Legal vs. Clinical judgments Physicians determine capacity, when to seek substituted judgment

5 How Common is incapacity Medical inpatients Mental illness Intensive care units, nursing homes Neurodegenerative diseases

6 Commonly Encountered Conditions Alzheimer s Disease Parkinson s Disease Stroke Traumatic rain Injury End of Life

7 The four Decision Making Abilities that Constitute Capacity Understanding Appreciation Reasoning Expressing a choice

8 Understanding Grasp fundamental meaning of information Risks/Benefits/Alternatives/Refusal Tell me in your own words.

9 Appreciation Application of Facts to one s own life Acknowledgement of illness Choices consonant with prior decisions, values, beliefs Finger amputation for pianist vs. psychiatrist questions

10 Reasoning Manipulate facts and concepts to arrive at logical coherent decision Process by which a decision is reached How did you decide

11 Communication a Choice Clear and consistent choice Undue influence

12 Approaches to Assessment Semi-structured Interview Mini Mental State Exam MacArthur Competence Assessment tool for Treatment Assessment of Capacity for Everyday decisions Capacity to treatment Interview Resident Assessment Instrument /Minimum Data set 2.0 * Only Supplement to Clinical Evaluation

13 The Decision Capacity Gradient Sliding Scale Approach Not all components must carry equal weight Varies directly with seriousness of likely consequence of patients decisions Dimensional

14 Challenges Refusal of assessment Family disagrees with assessment Consequences of finding incompetence Situational competence in some areas

15 Advance Healthcare Directive May Contain - living will - power of attorney Only 10-30% of older adults have advanced directives

16 Progressive Surrogacy Advance directives to decide proxy If none look for family consensus Hierarchy of relatives - spouse - adult child - parents of patient - siblings

17 Guardianship Assigned by judge Reasons include No healthcare surrogate/next of kin Feuding first degree relatives Next of kin clearly acting in self interest

18 Family Members Decisions ½ uses substitute judgment ½ best interests

19 Reasons for not using Substituted Judgment No discussion of healthcare preferences Incorporating quality of life into decision Unrealistic expectations of /for patient Influence of healthcare professionals

20 Palliative and End of Life Care Right to refuse medical interventions Right to terminate medical interventions - Artificial nutrition and hydration

21 End of Life Treatment Decisions Age 60 42% require decisions in final days 70% lacked decision making capacity 33% of them lacked advanced directives

22 Difficult Cases Care providers come to agreement - best interest standard incorporating knowledge of patient Shared understanding of caregiving team critical

23 Consent for Sex Issues include - voluntariness - recall learning form past experiences

24 Tip / Probabilities Low understanding not likely to have capacity Appreciation better test in psychiatric patients Reasoning better test in medical patients

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