Deciding for Others

Question 1

Among psychiatric patients, ____ has been reported to be the strongest predictor of incapacity

Answer 1

Among psychiatric patients, lack of insight (the lack of awareness of illness and the need for treatment) has been reported to be the strongest predictor of incapacity

Question 2

Criteria for Assessment of Decision-making capacity

Answer 2

• Ability to communicate a choice
• Ability to understand the relevant information
• Ability to appreciate the situation and its consequences
• Ability to reason about treatment options

Question 3

Assessing the patient’s ability to communicate a choice

Answer 3

Ask the patient to indicate a treatment choice

Question 4

Assessing the patient’s ability to understand the relevant information

Answer 4

Encourage the patient to paraphrase the disclosed information regarding medical condition and treatment options

Question 5

Assessing the patient’s ability to appreciate the situation and its consequences

Answer 5

Ask the patient to describe their views on their medical condition, the treatment options, and their likely outcomes

Question 6

Assessing the patient’s ability to reason about treatment options

Answer 6

Ask the patient to compare the treatment options and their consequences, and to offer a formal selection of an offer

Question 7

___ may be helpful in assessing patient competence, particularly complex cases or when mental illness is present.

Answer 7

Psychiatric consultation may be helpful in assessing patient competence, particularly complex cases or when mental illness is present.

Question 8

Mini–Mental State Examination

Answer 8

Designed to quickly provide information as to a patient’s ability to make decisions. MMSE scores range from 0 to 30, with lower scores indicating decreasing cognitive function. No single cutoff score yields both high sensitivity and high specificity.

MMSE scores of less than 19 are highly likely to be associated with incompetence, and scores above 23 are highly suggestive of competence.

Question 9

MacArthur Competence Assessment Tool for Treatment

Answer 9

A structured interview that, unlike many other assessment instruments, incorporates information specific to a given patient’s decision-making situation. Quantitative scores are generated for all four criteria related to decision-making capacity, but evaluators must integrate the results with other data in order to reach a judgment about competence

Question 10

In administering tests of patient competence, . . .

Answer 10

. . . patients should generally be informed of the purpose of the evaluation, but they need not give explicit consent for the assessment to occur

Question 11

Utilizing the family as a resource for preserving some autonomy

Answer 11

Many states have statutes indicating the priority order in which family members may be approached; in general, the order is the spouse, adult children, parents, siblings, and other relatives.

Question 12

Formal guidelines of measuring patient competence to make decisions

Answer 12

There are currently no formal practice guidelines from professional societies for the assessment of a patient’s capacity to consent to treatment.

Question 13

Patient-Designated Proxy

Answer 13

As the name suggests. This is the clearest case for proxies. Just treat the proxy as you would the patient with regards to their decision making capacity.

Question 14

Family Members as Proxies

Answer 14

When a proxy is not designated, family members may serve as proxies. A spouse is usually the proxy for a mate, a child or children are usually appropriate for a widowed parent, and parents are the proxies of first choice for their minor children.

However, physicians need to ask family members why they believe an intervention is something their loved one would, or would not, want, in order to ensure that they are truly doing this in the patient’s interest.

Question 15

Significant Others as Proxies

Answer 15

It is possible that someone completely outside the family might have better idea of what the patient would want. If this is so, then this person would be in a better position to act as proxy for the patient. Of course this could easily generate a very volatile situation if the family members object.

This is often the case in situations where the patient no longer lives with family and has established a close and enduring relationship with another person but never married him or her.

Question 16

If a patient has had no meaningful contact with his family for decades, . . .

Answer 16

If a patient has had no meaningful contact with his family for decades, it makes no sense to think a family member is the most suitable proxy

Question 17

Court-Appointed Proxies

Answer 17

May occur when there is no clear individual who is capable of serving in the capacity of a legitimate proxy.

If a court does appoint a guardian to make health care decisions, the guardian’s decisions have priority over those of any other proxy. If the physician or the family disagrees with the court-appointed guardian’s decisions, they cannot overrule him, but they can challenge the decision in court.

Question 18

Standards for making proxy decisions

Answer 18

• Substituted judgement
• Best interests
• Reasonable treatment (superceded by the other two, but when other two are unclear this is a fall-back)

Question 19

Substituted judgement standard

Answer 19

All the proxy does is step in as a substitute for the patient and report the patient’s wishes to the physician. This means the proxy must know how the person wants to be treated if she becomes an incapacitated patient. There are three ways a proxy can know this:

1. The patient could have explicitly told the proxy
2. The patient could have implicitly made clear what she wants, perhaps by offhand comments about how silly it is to keep unconscious people alive on machines for months, and so forth.
3. The patient could have revealed enough about her thinking and values so the proxy knows what she wants, even though the matter was never discussed or even mentioned (this is the weakest of the three, but may be valid in some cases where values are clear)

Question 20

Best interests standard

Answer 20

The best interests standard is what the proxy falls back on when the patient’s wishes are not known and the substituted judgment standard cannot be used.

The interests in best interests are the interests of the patient, what will best net benefit the patient. The word ‘‘best’’ in best interests simply means that the proxy should decide on the basis of what he thinks is good for the particular patient—that is, what he thinks will truly benefit him.

Question 21

Reasonable treatment standard

Answer 21

Used when the substituted judgement and best interests standards are inapplicable. This is rare, but occurs most often in cases of permanent unconsciousness.

Treatment of a PVS patient is not reasonable because it is of no possible benefit to the patient, withdrawing it is of no burden to the patient, and providing the treatment is a considerable burden for others

Question 22

When dealing with a permanently unconscious patient, you are. . .

Answer 22

. . . past the realm of the patient’s “interests.”

Question 23

Advance directives

Answer 23

Our instructions for health care that will become effective if we ever lose our decision-making capacity.

We can set up advance directives two ways: (1) We can prepare written directions about how we want to be treated if certain conditions afflict us (treatment directives), and (2) we can designate someone to report our instructions or, if we didn’t give instructions, to make decisions for us(proxy designations).

Question 24

Living Will

Answer 24

A legal document similar to the legal will. A living will allows people to set forth their wishes to have life-support systems withheld or removed in certain situations.

Question 25

Medical Care Directive

Answer 25

A written instruction indicating the care people want if they should ever become incapacitated. More broad than a living will, as it does not deal with end-of-life explicitely.

Anyone can make one, the directions may involve providing or forgoing certain treatments, and the language describing the medical problems that might develop is much more concrete than that of a living will.

Question 26

Two types of proxy designation

Answer 26

1. Durable power of attorney, which includes healthcare considerations as well as financial and legal considerations
2. Health care proxy designation, which simply provides the power of a healthcare proxy.

Question 27

parens patriae

Answer 27

The legal concept of safeguarding the health and welfare of children, especially those who are younger and less able to demonstrate capacity/competency to make decisions on their own

This interest can and does at times trump parental interests in deciding for their own children, and it can also serve to dismiss a child’s own declared preference for avoiding some medical procedures.

Question 28

“mature minor” exception

Answer 28

Provides for minors to give consent to medical procedures if they can show that they are mature enough to make a decision on their own.

Formal statue in some states, matter of common law in others. In either instance, it provides a legal mechanism for children to avoid having to obtain parental consent to certain medical procedures.

Question 29

How does the state evaluate a child’s maturity?

Answer 29

“Judges must take into account the age and situation of the minor to determine maturity, in addition to addressing factors and conduct that can help evidence the degree of maturity”

The Arkansas statue is representative: “any unemancipated minor of sufficient intelligence to understand and appreciate the consequences of the proposed surgical or medical treatment or procedures, for himself [may offer consent].”

More consistently applied when the minor is at least 16 years old and the procedure is not regarded as particularly serious.

Question 30

“emancipated” minors

Answer 30

The law formally recognizes some minors to be “emancipated” from their parents, and so legally able to consent to virtually all types of health care (although even here, some states make exceptions).