GERI Elder Informed Consent

Question 1

What are the 3 criteria for informed consent?

Answer 1

1. VOLUNTARY and FREE OF COERCION. 2. Pt must be given adequate information (in language they understand) to make a decision. 3. Pt must have CAPACITY.

Question 2

What is competency?

Answer 2

The capacity to understand the consequences of one’s decisions

Question 3

If a patient lacks competency, what must happen?

Answer 3

They must establish a power of attorney or guardianship.

Question 4

Who can determine if a pt has capacity or not?

Answer 4

A physician

Question 5

Are health providers identifying patients with a lack of decision-making capacity?

Answer 5

No, not well. Only identifying 1 in 4 patients. Fail to identify 30-50% of patients who lack decision making capacity.

Question 6

What are the 4 standards that one must meet in order to have full decision making capacity?

Answer 6

1. Ability to communicate a choice 2. Understand the relevant information 3. Appreciate the medical consequences of the situation. 4. Reason for treatment choices.

Question 7

What is a good way to ensure a patient understands the relevant information of their medical plan?

Answer 7

Ask the patient to tell you in their own words what you told them about. —> Have them repeat the problem with their health, the recommended treatment, possible risks and benefits, alternative treatments, and risks/benefits of no treatment.

Question 8

What must you always discuss with a patient when starting them on a new medication or recommending a new procedure?

Answer 8

The RISKS and BENEFITS.

Question 9

What are the 6 indications for formal capacity assessment?

Answer 9

1. Change in mental status 2. Pt refuses standard of care 3. Patient consents quickly to invasive or risky treatment. 4. Pt refuses treatment but does not say why. 5. Refusal of treatment seems irrational. 6. Pt reverses choice without reasoning.

Question 10

Is a lack of capacity more commonly seen in men or women?

Answer 10

Men!

Question 11

What are the common causes of lack of capacity in men?

Answer 11

Neurologic issues or substance use.

Question 12

What are the the common causes of lack of capacity in women?

Answer 12

1. Endocrine disorder 2. Mood disorder 3. Psychiatric illness

Question 13

Are men or women more likely to leave against medical advice?

Answer 13

Men!

Question 14

What are the 4 risk factors for impaired decision making?

Answer 14

1. Altered mental status 2. Extreme age 3. Fear or discomfort in health-care setting 4. Multiple sensory limitations (i.e. vision and hearing).

Question 15

Do patients with moderate dementia have decisional capacity?

Answer 15

YES, usually.

Question 16

Do patients with severe dementia have decisional capacity?

Answer 16

By definition they do NOT.

Question 17

Do most patients with Parkinson’s disease have decisional capacity?

Answer 17

YES. Usually little to no cognitive impairment until Parkinson’s dementia progresses.

Question 18

If a patient has low health literacy, are they able to have decisional capacity? If so, what consequences can this cause?

Answer 18

YES. But this can lead to higher uncertainty in health decisions and decisional regret.

Question 19

Are those with mental retardation able to make medical decisions?

Answer 19

50% mild retardation-yes, 18% moderate retardation-no.

Question 20

What is necessary when making medical decisions for a patient with mental retardation?

Answer 20

A patient-centered team approach, involving the patient and a power of attorney early on.

Question 21

Are patients with psychiatric disorders able to make medical decisions?

Answer 21

It depends! - 50% of hospitalized patients with schizophrenia or symptomatic bipolar disorder have impaired capacity. - 25% of hospitalized patients with depression have impaired capacity.

Question 22

How do you assess one’s capacity?

Answer 22

1. Directed clinical interview 2. Formal assessment tools 3. History from family 4. Physical assessment 5. Laboratory testing and neuroimaging studies 6. Mental status examination

Question 23

What is the gold standard assessment tool for capacity?

Answer 23

MacArthur Competence Assessment Tool - Takes 20-30 mins - Used by psychologists and psychiatrists - Useful for routine cases

Question 24

The Mini-Mental Status Examination (MMSE) can be used to assess capacity. What score is suggestive of this?

Answer 24

<21.

Question 25

Can you determine a patient’s lack of capacity by 1 MMSE?

Answer 25

NO! This should never be used alone to assess capacity! This should be assessed over time.

Question 26

Who is the best person to evaluate a patient’s capacity?

Answer 26

Their PCP! Research shows that PCP’s judgment is equivalent to that of a psychiatrist.

Question 27

When should a psychiatrist be involved in this decision?

Answer 27

1. Need help in deciphering why the patient does not want treatment. 2. The patient lacks trust in providers involved in their care. 3. Pt feels rushed or overwhelmed when making the decision. 4. Underlying psychopathology is interfering with decision making. 5. Involvement of legal proceedings.

Question 28

What can you do as a provider to help the patient in understanding how to make a medical decision?

Answer 28

Provide the patient with pictures and written information in terms and language they can understand. Repeat information on multiple visits and include other family members in the conversation.

Question 29

Who are surrogate decision makers?

Answer 29

1. Family: spouse, partners, children, siblings 2. Friends 3. Ethics committees 4. Decision making for the unbefriended elderly.

Question 30

What are other types of decision makers that are assigned legally?

Answer 30

Conservatorship and Powers of Attorney (Heath care OR general).

Question 31

How are surrogate decision makers decided upon for patients without capacity?

Answer 31

1. Directed via a living will. 2. Delegated —> health care proxy. 3. Default —> state surrogacy laws 4. Displaced —> guardianship

Question 32

What are the 4 critical questions to ask when a patient is refusing medical care?

Answer 32

***1. Does the patient understand the benefits vs risks? 2. Is the refusal based on fear? 3. Is the refusal based on pain? Prior bad experience? Inability to pay for treatment? 4. Depression?

Question 33

When deciding on a patient’s capacity, what should you always favor?

Answer 33

The patient’s autonomy!

Question 34

What should you do before making an official decision about someone’s capacity?

Answer 34

Evaluate the patient at 2 separate times.