Assessing Medical Decision-Making Capacity and Obtaining Informed Consent Flashcards
When and where was the term “informed consent” first used?
1957 in a California appeals court
What two principles are addressed in informed consent?
Autonomy and Beneficence
What is the optimal result of informed consent?
Shared decision-making
How do you promote shared decision-making?
- Encourage the patient to play an active role in decisions
- Encourage that patients are informed
- Protect the patient’s best interests
- Try to persuade/dissuade patients
Difficulties with informed consent: Providers
- Use of technical language/lack of communication skills
- Difficulty telling patient uncertainty intrinsic to medical information
- Fear of overloading the patient with info/alarming the patient
- Time pressure
- Diminishing the process as bureaucratic and unnecessary
Difficulty with informed consent: Patients
- Limited understanding
- Inattentive/distracted
- Overcome by fear and anxiety
- Selective hearing
- May believe decisions are physicians’ prerogative
What should be on an informed consent document?
Recommendation, Indications, Risks, Benefits, Alternatives, and Patient’s agreement to the recommended care
Standards for Consent: Professional Standard
Physician relies on a judgment about what colleagues in similar situations would disclose
Standards for Consent: Reasonable Person Standard
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
Implied Consent
Physicians presume patient would give consent if they were able to do so
What is recommended for treatment involving implied consent?
Do what is medically necessary to preserve life/function; NOT everything that is medically important
What is important to do when there is no surrogate available?
Document what was done to identify and/or contact surrogate decision-makers
What does implied consent defend physician against?
Battery (however, does not protect them against negligence)
BENEFICENCE is in effect
What is the Patient Self-Determination Act?
- Federal law passed in 1990 and put into effect Dec 1st, 1991
- Requires many providers, at the time of admission or enrollment, to provide information to patients regarding their rights under state laws governing advance directives
What advance directive rights do people have under the Patient Self-Determination Act?
- …to participate in and direct their own healthcare decisions
- …to accept or refuse medical or surgical treatment
- …to prepare an advance directive
- The receipt of information on the provider’s polices that govern he utilization of these rights
What are the top two reasons an advanced care directive does not get filed?
- Can’t be found or healthcare staff don’t know about it
2. Patient has no idea what it says
Provider has obligation to act in accord with patient’s wishes, EXCEPT when:
- Patient lacks medical decision making capacity
- Patient wants more than medical standard: medical futility debates
- Pt requests not in keeping with standards of tx
- Conscientious refusal by physician
Competence vs Medical Decision Making Capacity
Competence: a LEGAL decision; “can you manage your finances, sell your house, buy property, etc.”
MDM Capacity: determined by a qualified healthcare professional
If patient lacks MDM capacity, what can they not do?
Give informed consent
Determination of capacity is built on elements that are…
a CONTINUUM (more/less) rather than a threshold (either/or)
Is medical decision making capacity global?
No, it is specific in TIME and TASKS
What four things are required for patients’ capacity to consent or refuse care?
- Understand relevant information
- Appreciate medical situation and possible consequences
- Communicate choice
- Engage in rational deliberation about values in relation to physician recommendations and treatment options
What are the three steps in determining MDM capacity?
- Engage patient in conversation
- Observe patient’s behavior
- Talk with third parties - family, friends, staff
What type of patients require further evaluation of their mental capacity?
Those who refuse low-risk, high-benefit treatment, without which they face serious injury or death
What is the most common exam used to test for cognitive functioning, psych disorders, or organic conditions that affect medical decision making capacity
Mental Status Exam
What should be avoided when determination of capacity is problematic?
Quickly contacting mental health professional or the law
What should always be documented as far as MDM capacity is concerned?
How MDM capacity was assessed, by whom, and when
Durable Power-of-Attorney
-
Is a DOCUMENT, not a person*
1. Important for EOL care planning
2. ID’s who will make decisions when patient lacks MDM capacity
What MDM capacity elements do surrogate decision-makers have to meet?
-
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
When would you use Substituted Judgement?
When surrogate is present who knows what the patient would want
When would Surrogate use Best Interest?
When patient’s preferences are unknown
