perils and pitfalls of the incapacitated patient providence health care

Perils and Pitfalls of the Incapacitated Patient

Andi Chatburn, DO, MALeanne Park, RN, JDJeremy Williams, RN

Mission As people of Providence, we reveal God’s love for all, especially the poor and vulnerable, through our compassionate service.

Vision Together, we answer the call of every person we serve: Know me, care for me, ease my way.®

Disclosures

• Andi Chatburn, DO, MA none• Leanne Park, RN, JD none• Jeremy Williams, RN none

Objectives

• Review essential elements of Informed Consent and when Implied Consent is sufficient

• Learn how to assess capacity in both emergency and routine situations

• Discover who can make decisions for the incapacitated patient

• Explore WA state laws and procedures related to Involuntary Treatment for Mental Health

• Learn appropriate applications of the Single Bed Certification and how it affects your practice

Ethics Terms

• Autonomy• Decision Making Capacity • Surrogate Decision Maker*• Substituted Judgment

Legal Terms

• Competence• Guardian • POA- Power of Attorney• ITA- Involuntary Treatment Act

Psychiatric Terms

• DMHP- Designated Mental Health Professional

• Initial Detention• Grave Disability• Less Restrictive Alternative• Likelihood of serious harm

Autonomy

Capacity

Informed ConsentProcess

Implied Consent Emergency

Involuntary Treatment

Minors & Patients

with Guardians

Serio

us H

arm

Case of Mr. A

Public Domain US Navy Anna Kiner

Case of Mr. A

• 53 yo construction worker• Brought in by EMS after MVA • Unconscious, uncommunicative• Acute abdominal pain, hypotensive • Suspected abdominal bleeding and

potential for head injury• Emergency surgery recommended

Autonomy

Capacity




Minors & Patients

with Guardians

Serio

us H

arm

Implied Consent

Patient unable to express preference No surrogate available Acute- Immediate action required to: Save Life or Save Limb Reasonable person (non-experimental)

Perils & Pitfalls

• Whenever possible, 2 clinical providers should document severity and imminence of risk

• Implied consent ONLY applies to the procedure that is emergently necessary

• Less invasive temporary alternatives don’t exist

Application of Implied Consent

For Mr. A:

– YES: Exploratory laparotomy with splenectomy, craniotomy

–NO: PEG tube placement

Perils & Pitfalls

Implied consent cannot be used to justify a procedure if a

patient has previously refused

.phcimpliedconsent

WA Surrogate Hierarchy

Guardian Durable Power of Attorney – HC Spouse or Registered Domestic Partner Adult Children Living Parents Adult Siblings

.phcsurrogatehierarchy

How to Find a Surrogate

Consult Social Work

Sam Caplet “Don’t Let Go”

Case of Mr. A … 4 months later


Case of Mr. A

• 53 yo construction worker• Admitted with dyspnea, fatigue and

recent history of a TBI• Found to have symptomatic bradycardia• Refusing recommended Implanted

Cardiac Monitor

Evaluation for Capacity

• Does Mr. A have the capacity to refuse recommended interventions?

• Any physician can make a determination of incapacity for medical decision making

?

Autonomy

Capacity




Minors & Patients

with Guardians

Serio

us H

arm

INFORMED CONSENT IS A PROCESS, NOT A PIECE OF PAPER

Autonomy

Capacity




Minors & Patients

with Guardians

Serio

us H

arm

Informed Consent

• Physician’s responsibility• Usually an ongoing discussion• Involves shared decision-making• Form is a written verification of the

process

Components of Informed Consent

• Nature and character of proposed treatment and procedures

• Anticipated results• Recognized possible alternatives• Recognized serious possible risks,

complications, and anticipated benefits–Proposed treatment–Alternatives

.phcinformedconsent

Capacity- Medical

Capacity is both specific and dynamic. Specific Question Specific Time Dynamic- can change based on time and

question

Appelbaum, P. Assessment of Patient’s Competence to Consent to Treatment. NEJM. 357; 18. 2007.

Pitfalls & Perils

• Clinicians regularly fail to recognize incapacity

• 2.8% of Healthy Elderly control patients in community lacked capacity

• 26% of Elderly Medicine Inpatients lacked capacity

• Physicians recognized incapacity only 42% of the time

Sessums, L. et al., Does this Patient Have Medical Decision-Making Capacity? JAMA 206; 4. 2011.

CURVES Mnemonic for Capacity

Choose & Communicate Understand Reason Value Emergency Surrogate

Chow, et al. CURVES: a mnemonic for determining medical decision-making capacity and providing emergency treatment in the acute setting. 2010 Feb; 137 (2): 421-7.

.phccapacity

Perils & Pitfalls

• Risk of poor communication skills:–Pseudo-incapacity occurs when the patient

is provided information in a way they cannot understand.• Ex: excessive medical jargon

– English as Second Language–Patients who communicate nonverbally


Additional Validated Tools

• Clock Drawing Test• ACE- Aid to Capacity Evaluation• MMSE <24/30 indicates delirium or dementia• MDAS (Memorial Delirium Assessment Scale)• MacArthur Competence Assessment Tool for

Treatment (MacCAT-T)• CAM- Confusion Assessment Scale


Low Risk High Risk

Capacity Spectrum

• Less invasive• Less detailed• Less teach back

• More invasive • More detailed• Complex teach back

5 Questions Adapted, 6th grade level

1. What is going on with your body right now?2. What treatment is being recommended to you?3. What might happen to you if you decide to

accept that treatment?4. What might happen to you if you don’t have

that treatment?5. What alternative are available and what are the

consequences of each?

Appelbaum, P. Assessment of Patient’s Competence to Consent to Treatment. NEJM. 357; 18. 2007.

.phccapacityquestions

Does Mr. A have capacity to refuse?

YES

Document Refusal

Informed Consent Policy

Refusal of interventions:Patients who have medical decision making capacity are allowed to be refuse recommended medical interventions and make what may seem like unreasonable or even harmful choices.

Soriano, M. and R. Lagman. When the Patient Says No. American Journal of Hospice & Palliative Medicine. 29(5) 401-404.

.phcrefusalofcare

Does Mr. A have capacity to refuse?

NO Find Surrogate

WA Surrogate Hierarchy

Guardian Durable Power of Attorney – HC Spouse or Registered Domestic Partner Adult Children Living Parents Adult Siblings

.phcsurrogatehierarchy

How to Find a Surrogate

Consult Social Work

Sam Caplet “Don’t Let Go”

Case of Mr. A… 2 months Later


Case of Mr. A

• 53 yo construction worker• Recovering from TBI, now at SLRI• Acute Psychotic Episode• Long acting depot antipsychotic • Found to have Paranoid Schizophrenia• Persistently banging head against wall,

refusing ALL medications

Autonomy

Capacity




Minors & Patients

with Guardians

Serio

us H

arm

• The individual must have a treatable mental disorder • Presents a danger to self, others, or

property and/or• Is Gravely Disabled

Criteria for Civil Commitment

Grave Disability

• Danger of serious physical harm resulting from a failure to provide for his or her essential human needs of health or safety

OR• Manifests severe deterioration in routine

functioning evidenced by repeated and escalating loss of cognitive or volitional control over his or her actions and is not receiving such care as is essential for his or her health or safety.

• Once provider has suspicion of treatable mental illness that poses risk of imminent harm • Three (3) hours to call DMHP for

Involuntary Treatment Act evaluations

Steps to Call DMHPs

DMHP Evaluation

• Has twelve (12) hours to evaluate patient and make detainment decision

• If they decline to evaluate patient- ask name and let them know you will document declination in record

• If they evaluate and release patient, consider discharge


• Single Bed Cert (SBC) or Psychiatric Bed• If DHMP detains:–72 hour initial detention–Potential for 14 day +–Pertains to Psychiatric treatment ONLY

Perils & Pitfalls

• ITA detention permits involuntary treatment:–Psychiatric medications (with exceptions)–Psychiatric therapy/treatment–Detention in facility (cannot leave AMA)

Perils & Pitfalls

• ITA does not authorize any other medical care, intervention, or treatment–Must evaluate patient for decisional

capacity– If patient lacks capacity, must communicate

with surrogates to make medical decisions

.phctriagesbc

.phcriskassessment

Case of Mr. A… 9 months later


Case of Mr. A- Part 4

• 53 yo construction worker• Hx TBI, Paranoid Schizophrenia• AICD placed due to arrhythmia• s/p splenectomy • Daughter now seeking placement and

asking “what happens next time he comes into the hospital?”

Autonomy

Capacity




Minors & Patients

with Guardians

Serio

us H

arm

Competence- Legal

Adults assumed competent Incompetence determined by a court Global- unable to make any decisions Need for referral to attorney with goal of

naming a Guardian ad Litem Guardian

Application for Guardianship

Consult Social Work

PHC Resources

• Social Work–Assist in searching for surrogate decision

maker– Start process to obtain a guardian–Assist in consulting DMHPs for consults

outside the PSHMC ED–Assist in consulting Telepsych for patient with

a treatble mental illness in a medical bed

PHC Resources: After Hours

• Call Social Work first• If Social Work not available, call the

Nursing House Supervisor at your facility

PHC Resources- PSHMC ED

• Psychiatry Triage:–Assist in consulting DMHPs–Assist in consulting psychiatry for a patient

with treatable mental illness–Assist in determining capacity for a patient

whose mental illness is complicating capacity determination

PHC Resources

• Office of Legal Affairs & Risk Management: –Assist in questions of guardianship, ex:

reviewing guardianship papers for validity–Assist in situations of conflict between

decision makers

PHC Resources

• Ethics Consultation:–Assist in situations of conflict between

decision makers or patient–Assist in conflict between patient’s known

wishes and surrogate decision making–Assist in situations of surrogate request for

medically non-beneficial interventions

PHC Resources

• Palliative Care: –Assist in determining goals of care with

patient, surrogate –Assist in patient naming a surrogate–Assist in conflict between patient/family for

an individual with a potential life threatening illness

PHC Resources

• Spiritual Care–Assist in supporting patients and families in

distress• Emotional• Relational• Physical • Spiritual

–Assist in finding, naming or determining a surrogate decision maker

Questions?

• Andi Chatburn, DO, [email protected]

• Leanne Park, RN, [email protected]

• Jeremy Williams, RN, [email protected]

mailto:[email protected]



perils and pitfalls of the incapacitated patient providence health care

Healthcare