scholarly journals Determining medical decision-making capacity in brain tumor patients: why and how?

2020 ◽  
Vol 7 (6) ◽  
pp. 599-612 ◽  
Author(s):  
Andrea Pace ◽  
Johan A F Koekkoek ◽  
Martin J van den Bent ◽  
Helen J Bulbeck ◽  
Jane Fleming ◽  
...  
Keyword(s):  
Decision Making ◽  
Brain Tumor ◽  
Medical Decision Making ◽  
Clinical Decision Making ◽  
Best Interests ◽  
Medical Decision ◽  
Surrogate Decision Making ◽  
Tumor Patients ◽  
Decision Making Capacity ◽  
Surrogate Decision

Abstract Background Brain tumor patients are at high risk of impaired medical decision-making capacity (MDC), which can be ethically challenging because it limits their ability to give informed consent to medical treatments or participation in research. The European Association of Neuro-Oncology Palliative Care Multidisciplinary Task Force performed a systematic review to identify relevant evidence with respect to MDC that could be used to give recommendations on how to cope with reduced MDC in brain tumor patients. Methods A literature search in several electronic databases was conducted up to September 2019, including studies with brain tumor and other neurological patients. Information related to the following topics was extracted: tools to measure MDC, consent to treatment or research, predictive patient- and treatment-related factors, surrogate decision making, and interventions to improve MDC. Results A total of 138 articles were deemed eligible. Several structured capacity-assessment instruments are available to aid clinical decision making. These instruments revealed a high incidence of impaired MDC both in brain tumors and other neurological diseases for treatment- and research-related decisions. Incapacity appeared to be mostly determined by the level of cognitive impairment. Surrogate decision making should be considered in case a patient lacks capacity, ensuring that the patient’s “best interests” and wishes are guaranteed. Several methods are available that may help to enhance patients’ consent capacity. Conclusions Clinical recommendations on how to detect and manage reduced MDC in brain tumor patients were formulated, reflecting among others the timing of MDC assessments, methods to enhance patients’ consent capacity, and alternative procedures, including surrogate consent.

All things considered: Surrogate decision-making on behalf of patients in the minimally conscious state

2020 ◽  
Vol 15 (3) ◽  
pp. 111-119
Author(s):  
L Syd M Johnson ◽  
Kathy L Cerminara
Keyword(s):  
Decision Making ◽  
Medical Decision Making ◽  
Vegetative State ◽  
Minimally Conscious State ◽  
Conscious State ◽  
Disorders Of Consciousness ◽  
Medical Decision ◽  
Surrogate Decision Making ◽  
Surrogate Decision ◽  
Minimally Conscious

The minimally conscious state presents unique ethical, legal, and decision-making challenges because of the combination of diminished awareness, phenomenal experience, and diminished or absent communication. As medical expertise develops and technology advances, it is likely that more and more patients with disorders of consciousness will be recognized as being in the minimally conscious state, with minimal to no ability to participate in medical decision-making. Here we provide guidance useful for surrogates and medical professionals at any medical decision point, not merely for end-of-life decision-making. We first consider the legal landscape: precedent abounds regarding unconscious patients in coma or the vegetative state/Unresponsive Wakefulness Syndrome (VS/UWS), but there is little legal precedent involving patients in the minimally conscious state. Next we consider surrogates’ ethical authority to make medical decisions on behalf of patients with disorders of consciousness. In everyday medical decision-making, surrogates generally encounter few, if any, restrictions so long as they adhere to an idealized hierarchy of decision-making standards designed to honor patient autonomy as much as possible while ceding to the reality of what may or may not be known about a patient’s wishes. We conclude by proposing an ethically informed, practical guide for surrogate decision-making on behalf of patients in the minimally conscious state.

Mature Minors and Parenting Disputes in Australia: Engaging with the Debate on Best Interests v Autonomy

2019 ◽  
Vol 42 (4) ◽  
Author(s):  
Lisa Young
Keyword(s):  
Decision Making ◽  
Medical Decision Making ◽  
Children's Rights ◽  
Children’S Rights ◽  
Best Interests ◽  
Medical Decision ◽  
Decision Making Capacity ◽  
Competency Based

Australia lags behind other jurisdictions in considering the relevance of a mature minor’s decision-making capacity to parenting disputes. Gillick competency, as it is known, is routinely discussed in the case of medical decision-making, however is ignored when it comes to parenting decisions concerning very mature minors. This article explores this failure and in particular considers a) the jurisdiction of the court to determine a matter when a child is competent; b) the extent to which the courts are entitled to ignore a child’s competency, based on their best interests; c) to the extent a court should, but does not, consider a child’s competency, why they do not; and d) the arguments for overriding, or not, competency where there is a discretion. The article concludes that the court needs to reconsider this area of law, highlighting that this would play a part in the larger project of giving due recognition to children’s rights in parenting proceedings.

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.

Rethinking individual autonomy in medical decision-making for young adults reliant on caregiver support: A case report and analysis

2021 ◽  
pp. 147775092110698
Author(s):  
Alexia Zagouras ◽  
Elise Ellick ◽  
Mark Aulisio
Keyword(s):  
Decision Making ◽  
Young Adults ◽  
Medical Decision Making ◽  
Life Experience ◽  
Pregnant Patient ◽  
Medical Decision ◽  
Individual Autonomy ◽  
Caregiver Support ◽  
Neurological Condition ◽  
Decision Making Capacity

There is a gap in the clinical bioethics literature concerning the approach to assessment of medical decision-making capacity of adolescents or young adults who demonstrate diminished maturity due to longstanding reliance on caregiver support, despite having reached the age of majority. This paper attempts to address this question via the examination of a particular case involving assessment of the decision-making capacity of a young adult pregnant patient who also had a physically disabling neurological condition. Drawing on concepts from adolescent bioethics and feminist critiques of bioethical theory, we argue that limited life experience, secondary to a disabling neurological condition, can result in a lack of adult-like capacity even in a patient who is legally an adult. In such cases, it may be that autonomy, to the extent that it is to be relevant and meaningful, must be viewed through a relational lens. Furthermore, clinicians may avoid unjustifiably paternalistic practices by working with the patient help her gain a better appreciation of the consequences of her decision, thereby calling forward her capacity rather than resorting to being directive in counseling. We conclude that lessons from this case can be used to approach ethically complex instances of medical decision-making in adult patients with normal cognition but diminished experiential maturity.

Bioethics in the field of pediatric surgery

2020 ◽  
Vol 69 (4) ◽  
pp. 483-492
Author(s):  
Marko Bašković ◽  
Dora Škrljak Šoša
Keyword(s):  
Decision Making ◽  
Legal System ◽  
Pediatric Surgery ◽  
Medical Decision Making ◽  
Treatment Strategies ◽  
Moral Dilemmas ◽  
The State ◽  
Best Interests ◽  
Medical Decision ◽  
Team Members

It is the professional responsibility of pediatric surgeons to follow the principles of maintaining life and alleviating suffering, often by questioning whether they have acted correctly. Apart from the moral dilemmas of choosing the best treatment strategies, they are often in dilemmas with the parents, who also involve their own “strategy” in the whole story, which they think is the most optimal treatment for their child, despite the contrary recommendations of the profession. Children, and especially adolescents, may be somewhat involved in medical decision making. Mostly the parent-physician-child / adolescent triangle agrees, but this is not always the case, which is why pediatric surgeons encounter problems. Ethical committees, composed of competent people, supported by the legal system of the state, who are able by consensus of team members to advocate and ensure the best interests of patients, must be activated for the full scope of the solution.

scholarly journals The Effects of Brain Tumours upon Medical Decision-Making Capacity

2019 ◽  
Vol 21 (6) ◽  
Author(s):  
Will Hewins ◽  
Karolis Zienius ◽  
James L. Rogers ◽  
Simon Kerrigan ◽  
Mark Bernstein ◽  
...  
Keyword(s):  
Decision Making ◽  
Brain Tumours ◽  
Medical Decision Making ◽  
Medical Decision ◽  
Decision Making Capacity
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