Lecture III: Advance Directives

Question 1

Describe the criteria for decision-making capacity

Answer 1

• Decision making capacity
o Different than legally competent
o Specific to the decision at hand
o Must have understanding of the relevant information AND the consequences of the decision made AND be able to communicate a choice
o CURVES- Choose and Communicate, Understand, Reason, Value (Emergency and Surrogate)

• Determining decisional capacity
o Simple tests of mental status
o May require evaluation by psychiatry
o Dependent on risk-benefit analysis (when they refuse our plan we check decision-making capacity)
• Higher degree of capacity desired to consent to high risk/ low benefit procedure
• Higher degree of capacity desired to refuse high benefit/ low risk procedure

Question 2

Power of Attorney for Health Care

Answer 2

(durable power of health care): a formally documented medical decision maker for a patient. The power of attorney is “activated when a patient is unable to make decisions for him/herself. “

Question 3

Living Will

Answer 3

A type of Advance Directive

Question 4

Surrogate Judgement

Answer 4

Surrogate judgment – speak for the patient according to what the patient has explicitly said he wants. Different than speaking in accordance w/ values (substituted judgment) or for what you think is best for the patient (best interest). Patients cannot always be explicit about what they want. Unforeseen circumstances. Ambiguity in medicine.

Question 5

Substituted Judgement

Answer 5

• If not formally documented, order of people who will be asked to speak for you (spouse, adult son or daughter, parent, adult brother or sister, other close relative, or in the absence of any relatives, a close friend)

Question 6

Advance Directives to Physicians

Answer 6

Directives to physicians: Advance Directives/living will, Do Not Resuscitate/No CPR, POLST (2-page document saying “In the event of X, I want…”)

Question 7

Describe complexities of using patient’s advance directives in a clinical setting

Answer 7

Patient preferences can change about a situation, once they are in the situation

Question 8

Four Box Model

Answer 8

Medical Facts
Patient Preferences
Quality of Life
Contextual Features

Question 9

DNR

Answer 9

• DNR/No CPR is specific to resuscitation in the event of cardiac arrest. Data on in hospital CPR: 30% survive to leave the hospital (on TV 67% survive long-term). Most typically used for patients w/ terminal illness or very poor quality of life. Legitimate concern that DNR is interpreted as “Do Not Treat”. Often confusion about which other life prolonging measures should be withheld: intubation, pressors, cardioversion.