Clinical Issues

2021 ◽  
pp. 151-175
Author(s):  
Timothy E. Quill ◽  
Judith K. Schwarz
Keyword(s):  
Decision Making ◽  
Advance Directives ◽  
Oral Intake ◽  
Decisional Capacity ◽  
Clinical Issues ◽  
Decision Making Capacity ◽  
Seriously Ill

All seriously ill persons should complete advance directives specifying indications for limiting future provision of food and fluids. AD’s for SED specify When oral intake is to be limited and What limitations are to be imposed. Two categories include: (1) withholding all assisted oral intake from a person who has lost decision-making capacity, and previously indicated her wish to not receive any assisted feeding, and (2) Comfort Feeding Only (CFO) which involves providing as much or as little food and fluid as the patient seems to desire. CFO has three subcategories: (a) “Self-feeding only”—limiting oral intake to what the patient is able to self-administer. (b) Both “self-feeding” and “caregiver assisted-feeding” in whatever amount the patient enjoys. (c) “Minimum Comfort Feeding Only” is a modification for those who had expressed a desire to SED but lost decisional capacity before implementation, but now seem to desire food or fluid.

Clinical Issues

2021 ◽  
pp. 34-59
Author(s):  
Timothy E. Quill ◽  
Judith K. Schwarz ◽  
V. J. Periyakoil
Keyword(s):  
Health Care ◽  
Decision Making ◽  
Advance Directives ◽  
Oral Care ◽  
Oral Intake ◽  
Informed Choice ◽  
Dry Mouth ◽  
Health Care Proxy ◽  
Decision Making Capacity ◽  
Seriously Ill

VSED requires a decisionally capable, seriously ill patient who makes an informed choice to intentionally hasten death because of unacceptable current suffering or fear of imminent future suffering. In addition to being well informed and determined, patients must have access to ongoing caregiving support and a committed clinician partner. The treating clinician must carefully evaluate the reasons for the patient’s request and her decision-making capacity. Most patients who forgo all oral intake, food and liquids, die peacefully from dehydration within ten to fourteen days. Difficult symptoms of thirst and dry mouth can be adequately relieved with good oral care and access to medications to relieve additional distress. Many patients will be reassured by awareness of the option of VSED even if they never actually exercise it. Completion of advance directives (both health care proxy and instructional) as well as MOLST forms are recommended for anyone initiating VSED, as many patients lose decision-making capacity late in the process.

The capacity to designate a surrogate is distinct from decisional capacity: normative and empirical considerations

2021 ◽  
pp. medethics-2020-107078
Author(s):  
Mark Navin ◽  
Jason Adam Wasserman ◽  
Devan Stahl ◽  
Tom Tomlinson
Keyword(s):  
Decision Making ◽  
Mental Illness ◽  
Medical Decision Making ◽  
Medical Decision ◽  
Decisional Capacity ◽  
Risks And Benefits ◽  
Relative Risks ◽  
Decision Making Capacity ◽  
Cognitive Diseases ◽  
Surrogate Selection

The capacity to designate a surrogate (CDS) is not simply another kind of medical decision-making capacity (DMC). A patient with DMC can express a preference, understand information relevant to that choice, appreciate the significance of that information for their clinical condition, and reason about their choice in light of their goals and values. In contrast, a patient can possess the CDS even if they cannot appreciate their condition or reason about the relative risks and benefits of their options. Patients who lack DMC for many or most kinds of medical choices may nonetheless possess the CDS, particularly since the complex means-ends reasoning required by DMC is one of the first capacities to be lost in progressive cognitive diseases (eg, Alzheimer’s disease). That is, patients with significant cognitive decline or mental illness may still understand what a surrogate does, express a preference about a potential surrogate, and be able to provide some kind of justification for that selection. Moreover, there are many legitimate and relevant rationales for surrogate selection that are inconsistent with the reasoning criterion of DMC. Unfortunately, many patients are prevented from designating a surrogate if they are judged to lack DMC. When such patients possess the CDS, this practice is ethically wrong, legally dubious and imposes avoidable burdens on healthcare institutions.

Advance Directives, Do Not Resuscitate Orders, and Power of Attorney for Health Care

2018 ◽  
Author(s):  
Laura Stafman ◽  
Sushanth Reddy
Keyword(s):  
Health Care ◽  
Decision Making ◽  
Advance Directives ◽  
Advance Directive ◽  
Persistent Vegetative State ◽  
Living Will ◽  
Do Not Resuscitate ◽  
Power Of Attorney ◽  
Decision Making Capacity ◽  
Do Not Resuscitate Orders

In 2005, Terri Schiavo collapsed at home and was found by her husband without respirations or a pulse. She was resuscitated, but suffered severe anoxic brain injury and after 21/2 months was diagnosed as being in a persistent vegetative state. A court appointed her husband as her legal guardian as she did not have a written advance directive and had not specified a power of attorney for health care (POAHC), but heated court battles raged between her husband and her parents regarding who should be making decisions and what the appropriate decisions were. This case highlights the importance of writing down instructions for end-of-life care or designating someone to make decisions in their best interest in the event they could not make these decisions themselves. This review covers advance directives, do-not-resuscitate orders, and POAHC. Figures show an extended values history form, an example of a living will, the California’s Physician Orders for Life-Sustaining Treatment form, components of the CURVES mnemonic to assess decision-making capacity in critical/emergency situations, and activation and deactivation of power of attorney for health care. Tables list the most common types of advance directive and description of each, barriers to the use of advance directives, common themes in surgeons’ attitudes regarding advance directives, general requirements and exclusions for POAHC, and requirements for decision-making capacity in patients. This review contains 5 highly rendered figures, 5 tables, and 56 references

scholarly journals Medical Decision-Making in Oncology for Patients Lacking Capacity

2020 ◽  
pp. e186-e196
Author(s):  
Jonathan M. Marron ◽  
Kaitlin Kyi ◽  
Paul S. Appelbaum ◽  
Allison Magnuson
Keyword(s):  
Decision Making ◽  
Developmentally Disabled ◽  
Medical Decision ◽  
Decisional Capacity ◽  
Medical Decisions ◽  
Diminished Capacity ◽  
Decision Making Capacity ◽  
Minor Children ◽  
Oncology Practice ◽  
Do So

Modern oncology practice is built upon the idea that a patient with cancer has the legal and ethical right to make decisions about their medical care. There are situations in which patients might no longer be fully able to make decisions on their own behalf, however, and some patients never were able to do so. In such cases, it is critical to be aware of how to determine if a patient has the ability to make medical decisions and what should be done if they do not. In this article, we examine the concept of decision-making capacity in oncology and explore situations in which patients may have altered/diminished capacity (e.g., depression, cognitive impairment, delirium, brain tumor, brain metastases, etc.) or never had decisional capacity (e.g., minor children or developmentally disabled adults). We describe fundamental principles to consider when caring for a patient with cancer who lacks decisional capacity. We then introduce strategies for capacity assessment and discuss how clinicians might navigate scenarios in which their patients could lack capacity to make decisions about their cancer care. Finally, we explore ways in which pediatric and medical oncology can learn from one another with regard to these challenging situations.

Advance Directives, Do Not Resuscitate Orders, and Power of Attorney for Health Care

2016 ◽  
Author(s):  
Laura Stafman ◽  
Sushanth Reddy
Keyword(s):  
Health Care ◽  
Decision Making ◽  
Advance Directives ◽  
Advance Directive ◽  
Persistent Vegetative State ◽  
Living Will ◽  
Do Not Resuscitate ◽  
Power Of Attorney ◽  
Decision Making Capacity ◽  
Do Not Resuscitate Orders

In 2005, Terri Schiavo collapsed at home and was found by her husband without respirations or a pulse. She was resuscitated, but suffered severe anoxic brain injury and after 21/2 months was diagnosed as being in a persistent vegetative state. A court appointed her husband as her legal guardian as she did not have a written advance directive and had not specified a power of attorney for health care (POAHC), but heated court battles raged between her husband and her parents regarding who should be making decisions and what the appropriate decisions were. This case highlights the importance of writing down instructions for end-of-life care or designating someone to make decisions in their best interest in the event they could not make these decisions themselves. This review covers advance directives, do-not-resuscitate orders, and POAHC. Figures show an extended values history form, an example of a living will, the California’s Physician Orders for Life-Sustaining Treatment form, components of the CURVES mnemonic to assess decision-making capacity in critical/emergency situations, and activation and deactivation of power of attorney for health care. Tables list the most common types of advance directive and description of each, barriers to the use of advance directives, common themes in surgeons’ attitudes regarding advance directives, general requirements and exclusions for POAHC, and requirements for decision-making capacity in patients. This review contains 5 highly rendered figures, 5 tables, and 56 references

Best Practices, Enduring Challenges, and Opportunities for VSED

2021 ◽  
pp. 126-130
Author(s):  
Timothy E. Quill ◽  
Paul T. Menzel ◽  
Thaddeus M. Pope ◽  
Judith K. Schwarz
Keyword(s):  
Decision Making ◽  
Palliative Care ◽  
Best Practices ◽  
Advance Directives ◽  
Symptom Management ◽  
Early Phase ◽  
Terminal Illness ◽  
Care Providers ◽  
Decision Making Capacity ◽  
Challenges And Opportunities

VSED begins with excellent symptom management supported by experienced clinicians. VSED is largely patient controlled, but involvement of experienced palliative care providers and family is strongly recommended. Decision making capacity is frequently lost late in the process as death nears, so written advance directives to continue withholding food and fluids should be completed prior to initiating VSED to forestall any misunderstandings of the patient’s wishes. Challenges associated with VSED include its two week duration before death, the personal determination required, and the possibility of delirium in the latter stages that potentially compromises the commitment to forgo fluids. These challenges should be anticipated and planned for. The primary advantages of VSED include: 1) predictable two week duration from initiation to death; 2) alertness for the early phase, 3) no terminal illness requirement, 4) largely under the patient’s control, and 5) awareness of the possibility of VSED can provide comfort to those worried about unacceptable future suffering.

Assessment of Decision-Making Capacity

2020 ◽  
pp. 19-24
Author(s):  
Kenneth V. Iserson
Keyword(s):  
Decision Making ◽  
Medical Care ◽  
System Capacity ◽  
Decisional Capacity ◽  
Value System ◽  
Decision Making Capacity ◽  
Legal Term

Decision-making capacity (rather than “competence,” a legal term) is the ability to make decisions about one’s own medical care. Having decision-making capacity rests on the patient’s understanding their healthcare options and choosing an option consistent with their stable value system. Capacity is decision relative, meaning that the criteria to have decisional capacity depend on the complexity of the decision and the seriousness of possible outcomes. Individuals can have fluctuating decision-making capacity.

Effects of Visual Aids for End-of-Life Care on Decisional Capacity of People With Dementia

2020 ◽  
Vol 29 (1) ◽  
pp. 185-200 ◽  
Author(s):  
Wan-Zu D. Chang ◽  
Michelle S. Bourgeois
Keyword(s):  
Decision Making ◽  
End Of Life ◽  
End Of Life Care ◽  
External Support ◽  
Life Care ◽  
Visual Aids ◽  
Decisional Capacity ◽  
People With Dementia ◽  
Decision Making Capacity ◽  
Moderate Dementia

Purpose This study evaluated the decision-making capacity of persons with mild and moderate dementia on end-of-life care when using visual aids. A secondary purpose was to learn whether the judges naive to the experimental conditions would rate participants' decisional abilities as better when augmented by visual aids, thereby validating the behavioral changes due to the use of these external support. Method Twenty older adults with mild and moderate dementia demonstrated Understanding, Expressing a Choice, Reasoning, and Appreciation of 2 medical vignettes under 2 counterbalanced conditions: verbal alone or verbal with visual aids. Transcripts were analyzed and scored to measure decisional skills. Twelve judges rated participants' decisional abilities using a 7-point Likert scale. Results Participants demonstrated significantly better overall decisional capacity in Understanding, Reasoning, and Appreciation when supported by visual aids during the decision-making process. No significant differences between conditions were found in Expressing a Choice, the decisional skill Logical Sequence under Reasoning, and Acknowledgment under Appreciation. Overall, the judges' ratings validated these outcomes; the judges' ratings reflected greater agreement in the visual condition than in the verbal condition. Conclusions Findings indicated that visual aids (a) improved the decision-making capacity of individuals with dementia in comprehending medical information, employing supportive reasons, and relating this information to his or her own situation and (b) contain the potential for judges who majored or are majoring in speech-language pathology to reach a stronger consensus when determining the decision-making capacity of individuals with dementia.

Dealing with advance directives for critically ill adolescents

1992 ◽  
Vol 12 (5) ◽  
pp. 31-37 ◽  
Author(s):  
CH Rushton ◽  
ME Lynch
Keyword(s):  
Public Policy ◽  
Decision Making ◽  
Critical Care ◽  
Advance Directives ◽  
Nursing Practice ◽  
Critical Care Nurses ◽  
Essential Dimension ◽  
Decision Making Capacity ◽  
Improved Methods

Respecting the values and preferences of adolescents regarding treatment is an essential dimension of nursing practice. As public policy and societal thinking about the role of minors in healthcare decisions evolves, critical care nurses are in a pivotal position to provide leadership and guidance. Critical care nurses who care for adolescents should embrace the opportunity created by the PSDA to implement creative strategies for involving minors in decision making, seek improved methods of assessing decision-making capacity, and document the values and preferences of minors.

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