Decision-Making Capacity in Patients Who Are in the Early Stage of Alzheimer’s Disease and Who Request Physician-Assisted Suicide

Since the legalization of Medical Assistance in Dying (MAID) in Canada in 2016, there have been discussions regarding the extension of this service to patients who lose decision-making capacity but have made a prior advance request for physician-assisted suicide. Both caregivers and physicians have shown some support for allowing patients to make advance requests for MAID. The proposed changes to the legislation would remove the mandatory 10 day waiting period and include a waiver of final consent for those who loose decision-making capacity following their MAID request.

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Decisions and attitudes regarding participation and proxy in clinical trials among patients with impaired cognitive function

Dementia ◽

10.1177/1471301217737413 ◽

2017 ◽

Vol 18 (6) ◽

pp. 2049-2061

Author(s):

S Stormoen ◽

IM Tallberg ◽

O Almkvist ◽

M Eriksdotter ◽

E Sundström

Keyword(s):

Alzheimer’S Disease ◽

Alzheimer's Disease ◽

Decision Making ◽

Clinical Trials ◽

Cognitive Impairment ◽

Mild Cognitive Impairment ◽

High Risk ◽

Medical Decision Making ◽

Medical Decision ◽

Decision Making Capacity

Background Medical decision-making capacity is impaired in Alzheimer’s disease and mild cognitive impairment. Medical decision-making capacity depends on many different cognitive functions and varies due to situation and cognitive, social, and emotional status of the patient. Our aim was to analyze dementia patients’ capacity to estimate risks and benefits in different clinical trials and determine how cognitive decline affects their attitude toward possible participation and proxy consent. Methods Groups: Alzheimer’s disease (n = 20), mild cognitive impairment (n = 21) and healthy controls (n = 33). Two hypothetical clinical trials, a standardized interview and three visual analogue scales were used to investigate decisions, estimations, reasoning, and attitudes. Results A general positive attitude toward participation in clinical trials was shown among all groups. Both patients and controls motivated possible participation as “own-benefit” in the low-risk trial and to “help-others” in the high-risk trial. Individuals who accepted to participate in the high-risk trial scored lower in medical decision-making capacity in comparison to participants who would not have participated (p < .01). Patients in the Alzheimer’s disease but not mild cognitive impairment and healthy control groups underestimated risks and overestimated benefits in the high-risk/low-benefit trial (p < .05). A family member was most frequently chosen as possible proxy (91%). Conclusions Medical decisions and research consent should be interpreted with caution in patients who are already in early stages of dementia, as the patients’ acceptance to participate in high-risk trials may be due an insufficient decisional capacity and risk analysis, accelerated by a general desire to make good to society. We emphasize the use of a standardized tool to evaluate medical decisional capacity in clinical research.

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Clinical Considerations in Physician-Assisted Death for Probable Alzheimer’s Disease: Decision-Making Capacity, Anosognosia, and Suffering

Dementia and Geriatric Cognitive Disorders Extra ◽

10.1159/000500183 ◽

2019 ◽

Vol 9 (2) ◽

pp. 217-226 ◽

Cited By ~ 1

Author(s):

Jaime D. Mondragón ◽

Latife Salame ◽

Arnoldo Kraus ◽

Peter Paul De Deyn

Keyword(s):

Alzheimer’S Disease ◽

Alzheimer's Disease ◽

Decision Making ◽

Subjective Cognitive Decline ◽

Clinical Approach ◽

Early Assessment ◽

Assisted Death ◽

Clinical Prognosis ◽

Decision Making Capacity ◽

Testamentary Capacity

Background: Requests for physician-assisted death (PAD) in patients with cognitive impairment are complex and require careful consideration. Of particular difficulty is determination of whether the request is voluntary and well considered. Results: Euthanasia and physician-assisted suicide (PAS) are both legal in The Netherlands, Luxemburg, Colombia, and Canada. Euthanasia is legal in Belgium, while PAS is legal in Switzerland and Oregon, Washington, Montana, Vermont, and California (USA). Upon a PAD request, evaluation of the capacity to consent medical treatment is relevant for the decision-making process, while evaluation of testamentary capacity is appropriate before an advance euthanasia directive is written. Anosognosia assessment throughout the Alzheimer’s disease continuum provides essential and relevant information regarding the voluntary and well-considered nature of the PAD request; meanwhile, early assessment of hypernosognosia or subjective cognitive decline assists in formulation of a clinical prognosis. Furthermore, the assessment of physical and psychological suffering should incorporate verbal and nonverbal cues as well as consideration of the psychosocial factors that might affect due care criteria. Conclusion: The clinical approach to a PAD request should consider the legal framework and the decision-making capacity, assess memory deficit awareness and the perception of suffering, and evaluate mental competency when considered pertinent.

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