umms crit module i: understanding decision-making capacity gary blanchard, md division of geriatric...
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UMMS CRIT Module I: Understanding Decision-Making Capacity
Gary Blanchard, MDDivision of Geriatric Medicine UMMS
UMMS CRIT 2012 Module I: Understanding Decision-Making Capacity
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
• Upon completion of this lecture, the participants will be able to:
– Explain the principles of decision-making capacity.
– Recognize that no disease – including dementia –
automatically negates decision-making capacity.
– Identify common misconceptions about capacity.
– Apply the principles of capacity assessment in their daily
clinical encounters.
Objectives
UMMS CRIT 2012 Module I: Understanding Decision-Making Capacity
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
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Paternalism
UMMS CRIT 2012 Module I: Understanding Decision-Making Capacity
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Patients have the right to
make what we consider
to be “bad” decisions,
including refusing
treatment that we think is
in their best interest.
Patient Autonomy
UMMS CRIT 2012 Module I: Understanding Decision-Making Capacity
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
We as physicians must feel that a patient
has the capacity to make that
specific decision …
But there’s a catch …
UMMS CRIT 2012 Module I: Understanding Decision-Making Capacity
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
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Capacity vs. Competence
UMMS CRIT 2012 Module I: Understanding Decision-Making Capacity
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Retrieved April 16, 2010 from http://online.wsj.com/media/scales_art_160_20080808131250.jpg
Decision-Making Capacity
• Ideally, balance the respect for
a patient’s autonomy with
protecting a vulnerable patient
from the consequences of a
bad decision.
• No clear guidelines – clinical,
legal, and ethical
considerations
UMMS CRIT 2012 Module I: Understanding Decision-Making Capacity
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
– Expresses appreciation of the situation
– Understands consequences of the decision
– Manipulates information
– Reasons coherently
– Able to paraphrase
Standard of Informed Consent
UMMS CRIT 2012 Module I: Understanding Decision-Making Capacity
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
• In general, we only think of the notion of
capacity when someone disagrees with our
treatment plan.
• Literature suggest that 40-50% of medical
patients admitted to the hospital lack decision-
making capacity(!).
We Don’t Think Of It Enough …
UMMS CRIT 2012 Module I: Understanding Decision-Making Capacity
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
• Vast majority of people possess capacity
• Decision-specific (medical, financial, housing) –
not all of nothing … and may fluctuate!
• Standard proportional to risk (“sliding scale”)
– High Risk – High Standard
– Low Risk – Low Standard
Pearls/Guiding Principles
UMMS CRIT 2012 Module I: Understanding Decision-Making Capacity
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
• No disease alone – like dementia –
automatically negates decision-making capacity.
• No magic MMSE number (also important to
remember shortcomings of MMSE)
• A patient may continually forget the facts of
their condition – but can they express their
values when you repeat the scenario to them?
Who Lacks Capacity?
UMMS CRIT 2012 Module I: Understanding Decision-Making Capacity
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
• History (medical, psychiatric, social)
• Cognitive testing
• Functional assessment
• Assess a patient’s values and goals of care
Evaluating Capacity
UMMS CRIT 2012 Module I: Understanding Decision-Making Capacity
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
1. Communicate a choice
2. Understand the relevant information
3. Appreciate the situation and its consequences
4. Reason about treatment options
Core Principles
Unfortunately, no one useful, validated tool for assessing capacity currently exists.
Appelbaum, P.S. (2007). Assessment of patients’ competence to consent to treatment. New England Journal of Medicine, 357 (18). 1834-1840.
UMMS CRIT 2012 Module I: Understanding Decision-Making Capacity
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
• Clearly indicate preferred treatment option
–“Have you decided whether to follow your doctor’s
recommendation for treatment?”
–“Can you tell me what that decision is?”
–“What is making it hard you for to decide?”
Communicate a Choice
UMMS CRIT 2012 Module I: Understanding Decision-Making Capacity
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
• Grasp the fundamental meaning of information communicated by physician
“Please tell me in your own words what your doctor told you about …• the problem with your health now• the recommended treatment• the possible benefits and risks of the treatment and any
alternatives.
Understand the Relevant Information
UMMS CRIT 2012 Module I: Understanding Decision-Making Capacity
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
• Acknowledge medical condition and likely consequences of
treatment options
– “What do you believe is wrong with your health now?”
– “What do you believe will happen if you are not treated?”
– “Why do you think your doctor has recommended this
treatment?”
Appreciate the Situation and Its Consequences
UMMS CRIT 2012 Module I: Understanding Decision-Making Capacity
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
• Engage in a rational process of manipulating the relevant
information
– “How did you decide to accept or reject the recommended
treatment?”
– “What makes [chosen option] better than [alternative
option]?”
Reason about Treatment Options
UMMS CRIT 2012 Module I: Understanding Decision-Making Capacity
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Surrogate Decision-Making
• Reflects self-determination and Western notion of personhood,
especially pronounced in the United States (bioethical
hierarchy):
– Patient (who possesses decision-making capacity)
– Patient’s Known Wishes
– Substituted Judgments
– Patient’s Best Interests
UMMS CRIT 2012 Module I: Understanding Decision-Making Capacity
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
• Massachusetts Health Care Proxy Law
• Legal Guardian
• Section 12
Massachusetts rules
UMMS CRIT 2012 Module I: Understanding Decision-Making Capacity
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
THE SIMPSONS. Dr. Nick Riviera on THE SIMPSONS on FOX.
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Take Home
As a physician, there is no greater responsibility you possess than assessing your patient’s decision-making capacity.
UMMS CRIT 2012 Module I: Understanding Decision-Making Capacity
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Lessons Learned