Patient Capacity Slides PDF

WE MAKE DOCTORS PATIENT CAPACITY OBJECTIVES Explain patient’s decision capacity Define how decision capacity is obtained Contrast when patient is not able to decide Surrogate decision maker and legal frame  PATIENT CAPACITY Definition: a patient's ability to understa...

WE MAKE DOCTORS PATIENT CAPACITY OBJECTIVES Explain patient’s decision capacity Define how decision capacity is obtained Contrast when patient is not able to decide Surrogate decision maker and legal frame  PATIENT CAPACITY Definition: a patient's ability to understand and communicate a health care decision based on their preferences and values  PATIENT CAPACITY Adult patients are presumed to be competent (to have capacity) to make medical decisions. -Competence is a legal finding/Capacity or Incapacity is a medical finding (fainted, unconscious) -A patient may have capacity in one area, but not another (e.g., the right to refuse treatment) -A patient is presumed by law to be competent, unless a previous judicial determination of legal incompetence has been made A patient´s known preference must be respected - even after patient loses consciousness (this creates some very challenging issues) The right to refuse treatment should be evaluated most permissibly  PATIENT CAPACITY Minor patients (14yo) – patient seeks counseling, testing or treatment with respect to: Prenatal care/Abortion Counselling/testing for STDs, HIV Contraception, Addiction/Drug use Physician may encourage minor to speak with parents or counselors if this appears beneficial to the patient (conducive to a more thoughtful decision).  PATIENT CAPACITY MINORS - Absolute Emancipation Married Joins the Armed Forces Reaches the Age of Majority Court order grants emancipation Is having children emancipation? No, generally speaking In some states, a young woman is emancipated if: (a) she is pregnant or has children (b) she is over the age of sixteen A pregnant female is partially emancipated with respect to pregnancy matters  PATIENT CAPACITY Psychiatric Patients The issue is whether patient can understand his/her medical problem For example: a patient with an OCD, borderline or narcissistic personality disorder may nonetheless be able to make a competent decision regarding his/her medical treatment. Difficult cases may require a psychiatric evaluation to make this determination. Capacity presumption is rebutted where a patient has an active suicidal ideation (impaired judgment presumed).  PATIENT CAPACITY DNRs/DNIs, Living Wills, Durable Powers of Attorney & Surrogates Physicians should be aware if a DNR, Living Will (aka Advanced Directive) or Durable Power of Attorney exists for the patient to help guide the medical treatment decision process. Physicians may seek guidance from a court-appointed Surrogate in appropriate cases (petition must be filed with the court). Likewise, physicians should be encouraged to seek advices from their hospital ethics committee, when there are patient issues they cannot confidently resolve.  PATIENT CAPACITY To guide Patient´s treatment plan, follow this general priority list: (1) The patient´s express wishes (2) Advance directive (DNR, Power of Attorney, Living Will) (3) The legal guardian (court-appointed) or surrogate (hospital-designated) (4)If none of the above exists: obtain substituted judgment (what a loved one believes patient would want) by consulting, in this order: the spouse; offspring of legal age; parents; siblings; grandparents; grandchildren of legal age; other family; close friend/caregiver (5) In absence of available family members, implement the best interest of the patient standard (reasonable standard)  Capacity should be assessed and determined by the treating physician Assessing decision-making capacity Decision-making capacity for low-risk medical decisions can be assumed if the patient demonstrates understanding during a conversation. Indications Informed consent is required (e.g., prior to blood transfusions, invasive procedures). Incapacity is suspected. Prior to assessment Address low health literacy and communication barriers (e.g., hearing aids, medical interpreter). Treat reversible causes of incapacity (e.g., intoxication, delirium). Consider the cultural context of the decision and its impact on the patient's values. Directed interview: There are four required components. Choice: “What decision have you come to?” Understanding: “In your own words, can you describe the risks and benefits of the available options?” Appreciation “How would you describe your current health situation?” “Do you think you would benefit from some form of medical intervention?” Reasoning: “How did you come to your decision?” Further assessment: indicated if capacity remains uncertain after a directed interview Consider using a formal assessment tool. Repeat the assessment to evaluate for changes in capacity.  BIBLIOGRAPHY Fischer MD, Conrad, Oneto MD, Caterina, Master of the Boards, USMLE Medical Ethics, Kaplan Publishing (3rd ed. 2012) AMBOSS