Kendra J. Belfi, MD, FACP TAGS Ethics Conference March 6, 2013

Transcription

1 Kendra J. Belfi, MD, FACP TAGS Ethics Conference March 6, 2013

2 Describe the tension between Autonomy and Protection Describe basic components of assessing capacity Consider the importance of conversations about wishes and values while still able to communicate these

3 Societal values place a high value on autonomy The Law in this country places a high value on autonomy It s the right thing to do

4 The United States: Autonomy has become the trump card when in conflict with other ethical principles In some cultures, elders or the ill person is not to be disturbed with these questions which are to be handled by the appropriate child In some cultures, a council of the elders in the community makes decisions

5 The courts in the United States have concluded that an individual has virtually absolute right to refuse any treatment Persons must have capacity to make advance health care directives (but in Texas not to revoke them)

6 Sometimes if we think the acute illness has affected the patient s ability to make a decision (e.g. if the patient has delirium or is psychotic) Israeli law places a higher value on the sanctity of life than on autonomy (better than 50% chance of succeeding and we think the patient will thank us afterwards)

7 Competence to Stand Trial Testimonial Capacity Contractual Capacity Capacity to Consent to Medical Treatment Testamentary Capacity

8 Knowing the Nature of a Will Knowing the Nature and Extent of One s holdings (not to the penny at least broadly_) Knowing the Natural Objects of one s bounty (One s relatives or what people who would reasonably inherit) Freedom from undue influence.

9 As our society ages, clinical assessment of higher order functional capacities has become increasingly important. In areas like financial capacity, medical decision making capacity, medication compliance, and driving, society has a strong interest in accurately discriminating intact from impaired functioning Marson, et al (2000) Archives of Neurology: 57:

10 To what extent should we support an older person s autonomy (find her capable to act independently) To what extent should we protect an impaired older person (and ourselves) from risks/dangers caused by her failing capacities (find her incapable and restrict autonomy)

11 Individualistic society Tension between individual autonomy and protection Intergenerational transfer of wealth Breakdown of traditional family structure Increasing family disputes over care of elderly Issues: Control of health care and financial decisions Use of estate and inheritance

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13 MMSE Clock drawing Boston Naming test MiniCOG Objects named in a certain time frame Formal Neuropsych testing

14 Cortical Dementias: memory and language Alzheimer s Creutzfeld-Jacob (Multi=infarct) Subcortical dementia: Changes in speed of thinking and ability to initiate action Executive dysfunction Parkinson s Huntington s Multi=infarct

15 CLOX Or draw a clock and ask patient to put in the time 9:10

16 ADLs IADLs Evidence of poor judgment Example: an excellent cook who can no longer put a meal together Patients who believe appeals for money are bills to be paid Are there unpaid bills? Is there moldy food in the refrigerator?

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18 Information Comprehension and processing Ability to choose Ability to communicate a choice

19 Risks Benefits Alternatives

20 Does patient understand her current status Does executive function appear to be intact Is this clearly a voluntary decision (no coercion) Is there interference with patient s free will by substances, mental illness, personality disorder, undue influence

21 Language capacity (is the patient aphasic if so is there another way to communicate reliably) Receptive capacity of caregivers: (are we too busy to listen or to work at a non-usual method of communication)

22 Inability to understand risks, benefits and alternatives Clear coercion or inappropriate incentives Dense aphasia, mutism

23 Patient able to repeat risks (but doesn t believe they exist) Waxing and waning delirium Undetected change in value due to illness Patient s choice matches caregiver's values

24 Patient s choice does not match caregiver s values Religious beliefs

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26 Most physicians feel uncomfortable leading to psychiatric consults which are often not helpful. Frequently if there is concern about the patient s ability to make decisions there is a medical issue being reflected (e.g. delirium)

27 Informed Voluntary Competent: does patient have the mental and emotional capacity to consent medical competency : Issue arises in medical setting Involves a health care decision maker Decisions rarely subject to judicial review

28 Must understand that they are being asked to make a choice Must appreciate the consequences of the choice especially that the choice involves them Must have capacity to reason about the treatment (provide rational reasons for the choice) Must understand the treatment situation, treatment choices, respective risks/benefits.

29 We are much more likely to assume the patient is making an informed decision if they are agreeing with us Need to go back to basics: What does the patient understand (in his own words) about what is being proposed Does the patient understand he is being asked to make a choice that involves HIM Does that patient understand the consequences of agreeing to or refusing the intervention Is this decision consistent over time and with lifelong values.

30 From AMDA: Caring for the Ages 2/17/ year old widow in NF has a mammogram showing probable breast cancer but refuses an excisional biopsy 1) should the mammogram have been done? 2) would anyone have questioned if she agreed to treatment? Consent is not a form it is a process.

31 Explore understanding Explore fears Always seek the patient s best interest

32 A late stage dementia patient can still be given choices between two pieces of clothing or whether or not to attend an activity An early stage Alzheimer s patient may not have the capacity to execute a will but may be able to reliably tell you which of her children or friends that she trusts to make medical decisions for her. (MPOA) That same patient, however, may not be able to adequately understand a complicated medical consent issue.

33 Am J Geriatr Psychiatry Sep 19. Clinical and Ethical Aspects of Financial Capacity in Dementia: A Commentary: A Commentary.Marson DC. JAMA Feb 16;305(7): Finances in the older patient with cognitive impairment: "He didn't want me to take over". Widera E, Steenpass V, Marson D, Sudore R.

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35 TADA: patient must have capacity (based on reasonable medical judgment) to execute a directive Patient must have lost capacity (competence) also based on reasonable medical judgment before Directive to Physicians, Family and Surrogates OR MPOA comes into force. Patient does not have to be competent to revoke a directive.

36 Re: advance directives: don t try to impose YOUR values on the patient Re: treatment decisions: Language can make a big difference. We want to act always in the best interest of the patient while respecting the patient s wishes. If patient says no, gently explore why not (misunderstanding, fear.)

37 Most older persons still have the capacity to make good decisions and we should not lose that window of opportunity. Exploration of goals and values before asking a person to make specific decisions is extremely important to facilitating this conversation.

38 Respecting Choices: The Conversation Project: Dr. William Molloy (Canada): I Decide Speak for Yourself Program 3/23/13 at TCU from 8:30am to noon. Call or you may mbriggs@tcms.org to register.