decision capacity Flashcards
decisional capacity
-Medical ethics and US legal codes strongly favor individual freedom of choice regarding any sort of risky procedure
-Test thought and communication
-you must ascertain to a reasonable degree of certainty that the individual is able to perform these cognitive tasks
-Mental status exam
-Attention; memory; reasoning; reality orientation; language
-Determine decisional capacity
-To verify, ask the patient to state the nature of the procedure, the reasons for the procedure, the alternatives, and the risks back to you in their own words
capacity define
ability to:
-take in information,
-understand its meaning and
-make an informed decision using the information
-Capacity allows us to function independently
-Capacity is not the same as competence
-Includes Mental Skills Used to Function in Everyday Life
-Memory
-Language
-Ability to use logic
-Ability to calculate
-Ability and “flexibility” to turn attention from 1 task to another
-Executive functions
giving consent
-Understand the nature of the procedure
-Understand reason(s) for doing procedure, or consequences of not doing it
-Understand the consequences of doing the procedure
-Understand the risks involved in the procedure
-Be informed of alternative management, if any
-Be able to express an opinion
-Be able to demonstrate a reasoning process in making the choice
evaluation
-Evaluate patients without meds
-Evaluate when fully awake
-Try multiple times
-Sit patient up
-Evaluate with family member present
-Maintain active communication with family
-Can prevent future misunderstandings about treatment
patient autonomy
-Patients have the right to control what happens to their bodies
-Make sure family members are aware of these decisions and your medical opinion about them
-Ultimately, you may remove yourself from the case
consent
-Clinician must always obtain informed consent, and be backed by a witness
-Always document consent in the patient’s medical record. Be as specific as possible.
-Power of Attorney; documented Legal guardian; Spouse; Children; Parents; Siblings; Other living relatives; Physician
competence vs decisional capacity
-Physicians/clinicians determine “decisional capacity;”
-Only a judge determines “competence,” which is a legal term.
practical considerations for determining pt capacity and consetn
recommendations
-Assess the patient’s level of understanding about the disease and expectations for the future
-Assess how much information the patient wants to know
-Remain involved with patient care during the early, middle, and late stages
-Initiate discussions about the availability of coordinated, symptom-directed services such as palliative care early in the disease process; -> Curative to palliative
-Avoid phrases that can lead to negative interpretations such as abandonment and failure
table 1
-Prioritize what you want to accomplish during the discussion
-Practice and prepare – conducive environment
-Assess patient understanding – customize discussions
-Determine patient preference -> The big picture vs. all the details
-Presenting the information – simple; repeat
-Provide emotional support; support services
-Options for the future
clinicians role
(1) to the patient: “Do you understand what is going to happen next? How are you and your family coping with this news?”;
(2) to the subspecialist: “What are the expected benefits and harms from this new treatment? How much benefit accrues to the patient?”;
(3) To the health care team: “What additional resources can we mobilize for the patient?”
pts point of view
-Assess patient’s desire and readiness to receive the prognosis -> 80% vs. 20%
-Focus on communicating the prognosis without giving false hope
-Hoping for the best, planning for the worst
-Worst case vs. best case scenario
-Ask whether the patient thinks that hope is realistic or probable
-Providing the patient with a full spectrum of treatment options [e.g. clinical trials]
-Sequential treatment options
-Help the patient create realistic, achievable goals and hope
discussing prognosis
-Discuss prognosis after accurate cancer staging
-Coordinate key prognosis messages
-Discuss the natural history of the disease
-Treatment and its adverse effects and outcomes
-Probable quality of life
-Expected five- to 10-year survival rates, with and without treatment
-Address patient fears
cultural diversity
-Be careful to avoid stereotyping patients based on their culture
-Culture of the family, religion and spirituality, education, occupation, social class, friends, and personal preferences
-Asking open-ended questions
-Conflicts may arise when pt. wants ‘medically futile’ Rx
-Respectfully listen to patients’ beliefs and values and by negotiating mutually acceptable goals
