Assessing Medical Decision-Making Capacity and Obtaining Informed Consent

Question 1

When and where was the term “informed consent” first used?

Answer 1

1957 in a California appeals court

Question 2

What two principles are addressed in informed consent?

Answer 2

Autonomy and Beneficence

Question 3

What is the optimal result of informed consent?

Answer 3

Shared decision-making

Question 4

How do you promote shared decision-making?

Answer 4

1. Encourage the patient to play an active role in decisions
2. Encourage that patients are informed
3. Protect the patient’s best interests
4. Try to persuade/dissuade patients

Question 5

Difficulties with informed consent: Providers

Answer 5

1. Use of technical language/lack of communication skills
2. Difficulty telling patient uncertainty intrinsic to medical information
3. Fear of overloading the patient with info/alarming the patient
4. Time pressure
5. Diminishing the process as bureaucratic and unnecessary

Question 6

Difficulty with informed consent: Patients

Answer 6

1. Limited understanding
2. Inattentive/distracted
3. Overcome by fear and anxiety
4. Selective hearing
5. May believe decisions are physicians’ prerogative

Question 7

What should be on an informed consent document?

Answer 7

Recommendation, Indications, Risks, Benefits, Alternatives, and Patient’s agreement to the recommended care

Question 8

Standards for Consent: Professional Standard

Answer 8

Physician relies on a judgment about what colleagues in similar situations would disclose

Question 9

Standards for Consent: Reasonable Person Standard

Answer 9

Emerged in 1970 and has replaced Professional Standard in many states

One is required to disclose what a reasonable person would want or need to know in order to make an informed choice for or against proposed treatment

Question 10

Implied Consent

Answer 10

Physicians presume patient would give consent if they were able to do so

Question 11

What is recommended for treatment involving implied consent?

Answer 11

Do what is medically necessary to preserve life/function; NOT everything that is medically important

Question 12

What is important to do when there is no surrogate available?

Answer 12

Document what was done to identify and/or contact surrogate decision-makers

Question 13

What does implied consent defend physician against?

Answer 13

Battery (however, does not protect them against negligence)

BENEFICENCE is in effect

Question 14

What is the Patient Self-Determination Act?

Answer 14

1. Federal law passed in 1990 and put into effect Dec 1st, 1991
2. Requires many providers, at the time of admission or enrollment, to provide information to patients regarding their rights under state laws governing advance directives

Question 15

What advance directive rights do people have under the Patient Self-Determination Act?

Answer 15

1. …to participate in and direct their own healthcare decisions
2. …to accept or refuse medical or surgical treatment
3. …to prepare an advance directive
4. The receipt of information on the provider’s polices that govern he utilization of these rights

Question 16

What are the top two reasons an advanced care directive does not get filed?

Answer 16

1. Can’t be found or healthcare staff don’t know about it

2. Patient has no idea what it says

Question 17

Provider has obligation to act in accord with patient’s wishes, EXCEPT when:

Answer 17

1. Patient lacks medical decision making capacity
2. Patient wants more than medical standard: medical futility debates
3. Pt requests not in keeping with standards of tx
4. Conscientious refusal by physician

Question 18

Competence vs Medical Decision Making Capacity

Answer 18

Competence: a LEGAL decision; “can you manage your finances, sell your house, buy property, etc.”
MDM Capacity: determined by a qualified healthcare professional

Question 19

If patient lacks MDM capacity, what can they not do?

Answer 19

Give informed consent

Question 20

Determination of capacity is built on elements that are…

Answer 20

a CONTINUUM (more/less) rather than a threshold (either/or)

Question 21

Is medical decision making capacity global?

Answer 21

No, it is specific in TIME and TASKS

Question 22

What four things are required for patients’ capacity to consent or refuse care?

Answer 22

1. Understand relevant information
2. Appreciate medical situation and possible consequences
3. Communicate choice
4. Engage in rational deliberation about values in relation to physician recommendations and treatment options

Question 23

What are the three steps in determining MDM capacity?

Answer 23

1. Engage patient in conversation
2. Observe patient’s behavior
3. Talk with third parties - family, friends, staff

Question 24

What type of patients require further evaluation of their mental capacity?

Answer 24

Those who refuse low-risk, high-benefit treatment, without which they face serious injury or death

Question 25

What is the most common exam used to test for cognitive functioning, psych disorders, or organic conditions that affect medical decision making capacity

Answer 25

Mental Status Exam

Question 26

What should be avoided when determination of capacity is problematic?

Answer 26

Quickly contacting mental health professional or the law

Question 27

What should always be documented as far as MDM capacity is concerned?

Answer 27

How MDM capacity was assessed, by whom, and when

Question 28

Durable Power-of-Attorney

Answer 28

• Is a DOCUMENT, not a person*
  1. Important for EOL care planning
  2. ID’s who will make decisions when patient lacks MDM capacity

Question 29

What MDM capacity elements do surrogate decision-makers have to meet?

Answer 29

• Same as patient*
  1. Understanding of relevant info
  2. Appreciation of medical situation and possible consequences
  3. Ability to communicate
  4. Engage in meaningful deliberation about values relating to physician recommendations

Question 30

When would you use Substituted Judgement?

Answer 30

When surrogate is present who knows what the patient would want

Question 31

When would Surrogate use Best Interest?

Answer 31

When patient’s preferences are unknown