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.

Capacity, Informed Consent, and Guardianship

2017 ◽  
Author(s):  
Stephen L. Read ◽  
James E. Spar
Keyword(s):  
Decision Making ◽  
Informed Consent ◽  
Medical Decision Making ◽  
Case Law ◽  
Fundamental Principle ◽  
Medical Decision ◽  
Decisional Capacity ◽  
Decision Making Capacity ◽  
Management Capacity

Medical decision-making based on informed consent is a fundamental principle of ethical medical practice. When a patient lacks medical decisional capacity and is unable to give truly informed consent, an agent must be sought to act on the behalf of the person. This chapter reviews the principles underlying determination of the capacity to give informed consent regarding healthcare decisions in a clinical setting. Cognitive loss, emotional distress, or disengagement or the perception that the patient is choosing unwisely or as a result of influence may be concerns that lead to consultation. In contrast to the clear standards for medical decision-making capacity, statutory guidance and case law are essentially nonexistent regarding what standard applies to the capacity to create or to change an advance health directive (AHCD) or to change or designate a healthcare agent. In addition to current decision-making capacity, the consultant must address broader issues of functional or management capacity when the patient’s ongoing capacity to manage personal care and health is at issue, as is relevant to the petition for guardianship. A comprehensive forensic geriatric psychiatry consultation will assist with the care of the patient.

scholarly journals Psychiatric Illness and Medical Decision-Making Capacity: A Retrospective Study in Medical Settings

2020 ◽  
Vol 1 (2) ◽  
pp. 115-124
Author(s):  
Dinesh Sangroula ◽  
Pranita Mainali ◽  
Katsuhiko Hagi ◽  
Sachidanand Peteru
Keyword(s):  
Decision Making ◽  
Mental Illness ◽  
Medical Decision Making ◽  
Psychiatric Symptoms ◽  
Demographic Characteristics ◽  
Medical Decision ◽  
Psychiatric Diagnoses ◽  
Medical Settings ◽  
Decision Making Capacity ◽  
Significant Difference

Determination of medical decision-making capacity (DMC) is one of the common encounters in Consultation-Liaison Psychiatry (CLP) services. It is a common misbelief that patients with “psych history” lack capacity more often than patients without mental illness. The study aims to examine the relationship between mental illness and DMC in patients presented to acute medical settings. The study is a retrospective chart review, where data were collected from the patients admitted to the medical units and assessed for capacity by a psychiatrist. Clinical and demographic characteristics were compared between two groups (patients having capacity and lacking capacity) using t-tests or chi-square tests, as appropriate. The commonest reason for DMC evaluation requests was for the patients who wanted to leave the hospital against medical advice. Overall, 53% (52/98) of the patients evaluated for DMC were found to lack capacity. Group of patients lacking DMC had a significantly higher percentage of males (58% vs. 35%) but were significantly less employed (8% vs. 10%). No significant difference was observed in other demographic characteristics and primary psychiatric diagnoses (past and current) among the two groups. However, patients lacking capacity were found to have a significantly more occurrence of current (48% vs. 11%) and past (23% vs. 4%) history of neurocognitive disorder, and larger trend significance (31% vs. 15%) of active psychiatric symptoms. We conclude that patients with neurocognitive disorders and active psychiatric symptoms might have poor DMC but not all patients who have psychiatric diagnoses lack medical DMC. Larger studies especially in outpatient psychiatric settings are suggested to derive more conclusive results.

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.

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.

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

Medical decision-making capacity in patients with mild cognitive impairment

Neurology ◽  
2007 ◽  
Vol 69 (15) ◽  
pp. 1528-1535 ◽  
Author(s):  
O. Okonkwo ◽  
H. R. Griffith ◽  
K. Belue ◽  
S. Lanza ◽  
E. Y. Zamrini ◽  
...  
Keyword(s):  
Decision Making ◽  
Cognitive Impairment ◽  
Mild Cognitive Impairment ◽  
Medical Decision Making ◽  
Medical Decision ◽  
Decision Making Capacity

Assessing medical decision making capacity among cancer patients: Preliminary clinical experience of using a competency assessment instrument

2013 ◽  
Vol 13 (6) ◽  
pp. 1529-1533 ◽  
Author(s):  
Tatsuo Akechi ◽  
Toru Okuyama ◽  
Megumi Uchida ◽  
Koji Sugano ◽  
Yosuke Kubota ◽  
...  
Keyword(s):  
Decision Making ◽  
Clinical Practice ◽  
Cancer Patients ◽  
Medical Decision Making ◽  
Past History ◽  
Structured Interview ◽  
Assessment Instrument ◽  
Medical Decision ◽  
Dementia Patient ◽  
Decision Making Capacity

AbstractObject:This study investigates the usefulness of the Structured Interview for Competency and Incompetency Assessment Testing and Ranking Inventory (SICIATRI) for cancer patients, which is a structured interview that assesses a patient's competency in clinical practice.Methods:The SICIATRI, originally developed to measure patients' competency to give informed consent, were administered referred cancer patients who needed for assessing medical decision making capacity. The usefulness of the SICIATRI was investigated retrospectively. Recommendation for modification of the SICIATRI for cancer patients if applicable were made by the research team.Results:Among the 433 cancer patients referred for psychiatric consultation, 12 were administered the SICIATRI and all of the administration were conducted without big problems. All patients were 60 years or older. The most common purpose for competency evaluation was to analyze patients' understanding of the anti-cancer treatment proposed by oncologists, followed by their refusal of the treatment. Half of the patients (n = 6) were diagnosed with delirium and three among them were judged as having the most impaired status of a patient's competency. Two patients (17%) were diagnosed with major depression and another two (17%) were mental retardation and each one patient was diagnosed with dementia and past history of alcohol dependence. Among 6 patients without delirium 5 subjects including a dementia patient were judged as fully competent. Total of 5 small potential modifications of the SICIATRI for its use with Japanese cancer patients were recommended.Significance of results:Our experience suggests that the SICIATRI is a useful instrument for psycho-oncology clinical practice.

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