Medical Decision-Making for Adults Who Lack Decision-Making Capacity and a Surrogate: State of the Science

2018 ◽  
Vol 35 (9) ◽  
pp. 1227-1234 ◽  
Author(s):  
Hyejin Kim ◽  
Mi-Kyung Song
Keyword(s):  
Health Care ◽  
Decision Making ◽  
Medical Decision Making ◽  
Medical Decision ◽  
Medical Decisions ◽  
Decision Making Capacity ◽  
Final Sample ◽  
State Of The Science ◽  
Professional Guidelines

Background: Adults who lack decision-making capacity and a surrogate (“unbefriended” adults) are a vulnerable, voiceless population in health care. But little is known about this population, including how medical decisions are made for these individuals. Objective: This integrative review was to examine what is known about unbefriended adults and identify gaps in the literature. Methods: Six electronic databases were searched using 4 keywords: “unbefriended,” “unrepresented patients,” “adult orphans,” and “incapacitated patients without surrogates.” After screening, the final sample included 10 data-based articles for synthesis. Results: Main findings include the following: (1) various terms were used to refer to adults who lack decision-making capacity and a surrogate; (2) the number of unbefriended adults was sizable and likely to grow; (3) approaches to medical decision-making for this population in health-care settings varied; and (4) professional guidelines and laws to address the issues related to this population were inconsistent. There have been no studies regarding the quality of medical decision-making and its outcomes for this population or societal impact. Conclusion: Extremely limited empirical data exist on unbefriended adults to develop strategies to improve how medical decisions are made for this population. There is an urgent need for research to examine the quality of medical decision-making and its outcomes for this vulnerable population.

Emotions and Medical Decision-Making

2020 ◽  
Vol 83 (2) ◽  
pp. 174-194
Author(s):  
Amanda M. Gengler
Keyword(s):  
Health Care ◽  
Decision Making ◽  
Medical Decision Making ◽  
Medical Decision ◽  
Decision Making Process ◽  
Medical Decisions ◽  
Interactive Process ◽  
The Social ◽  
Life Threatening ◽  
Ethnographic Data

Sociologists have written surprisingly little about the role emotions play in medical decision-making, largely ceding this terrain to psychologists who conceptualize emotional influences on decision-making in primarily cognitive and individualistic terms. In this article, I use ethnographic data gathered from parents and physicians caring for children with life-threatening conditions to illustrate how emotions enter the medical decision-making process in fundamentally interactional ways. Because families and physicians alike often defined emotions as useful information to guide the decision-making process, both parties could leverage them in health care interactions by eliciting or demonstrating emotional investment, strategically deploying emotionally charged symbols, and using emotions as tiebreakers to help themselves and one another make choices in the midst of uncertainty. Constructing emotions as valuable in the decision-making process and effectively marshalling them in these ways offered a number of advantages. It could make decisions easier to arrive at, help people feel more confident in the decisions they made, and reduce interpersonal conflict. By connecting the dynamic role emotions can play in the interactive process through which medical decisions are made to the social advantages they can produce, I point to an underappreciated avenue through which inequalities in health care are perpetuated.

scholarly journals Inpatients’ opinion on quality of health care

Medicina ◽  
2009 ◽  
Vol 45 (3) ◽  
pp. 226 ◽  
Author(s):  
Daiva Brogienė ◽  
Romualdas Gurevičius
Keyword(s):  
Health Care ◽  
Decision Making ◽  
Factor Analysis ◽  
Quality Of Care ◽  
Quality Of Health Care ◽  
Health Care Services ◽  
Medical Decision Making ◽  
Medical Decision ◽  
Care Services

The aim of the study was to assess the inpatients’ opinion on the quality of hospital care based on the factor analysis and to identify the problem-oriented fields in quality of care. Material and methods. A multistage stratified probability sampling was performed in 22 general hospitals in Lithuania. A total of 2060 questionnaires were distributed during November 2006 and February 2007. The response rate was 97.38%; 2006 inpatients responded to the questionnaire; 1917 questionnaires (93.06%) were eligible for analysis. The modified survey instrument of Picker Institute Europe was used for inpatients. The method of survey was follows: each discharged inpatient filled out the questionnaire on the day of his/her discharge. The assessment of quality of care involved such aspects as patients’ communication with medical personnel, organizational issues and coordination of care, patients’ possibility of participation in medical decision-making, physical environment, accessibility to services, and safety of health care. Results. Six dimensions were identified from the factor analysis, explaining 51.48% of the variance. Cronbach alpha was 0.7931 for all dimensions. The majority (91.9%) of respondents evaluated health care services as good and very good. Inpatients were most satisfied with communication with their doctors. Even 91.5% of respondents noted that the doctors provided enough information about their health and treatment. The majority of inpatients gave high positive responses on respect showed to them and confidence with doctors. Correlation analysis confirmed a stronger positive correlation among three items of the global assessment of the quality and patients’ ratings on respect and confidence. Several problems were highlighted in the field of patients’ autonomy. The possibility of participation in medical decision-making was the dimension with the lowest level of patients’ rating. Less than half (42.3%) of inpatients noted that they did not have a possibility of participation in medical decision-making to the extent they were willing. Conclusions. Patients gave highly positive responses on the overall evaluation of the quality of health care services. The priority field in the improvement of health care quality is to create more possibilities for patients’ participation in medical decision-making. Results of the present study indicate that future studies need to include more detailed measurements of patients’ autonomy as dynamic changes are observed today in this field.

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.

Support for management medical decisions and the nature of uncertainty in them

2021 ◽  
Author(s):  
S.Yu. Zhuleva ◽  
A.V. Kroshilin ◽  
S.V. Kroshilina
Keyword(s):  
Decision Making ◽  
Medical Decision Making ◽  
Medical Information ◽  
General Scheme ◽  
The Body ◽  
Medical Decision ◽  
Problem Situation ◽  
Medical Decisions ◽  
Inaccurate Information ◽  
Individual Decisions

The process of making a medical decision is characterized by a lack of knowledge and inconsistency of the available information, the lack of the possibility of attracting competent medical experts, limited time resources, incomplete or inaccurate information about the patient's condition. These aspects may be the causes of medical errors, which lead to further aggravation of the problem situation. Purpose – it is necessary to define and justify managerial medical decisions and types of medical information in conditions of uncertainty, when each variant of the sets of outcomes of the situation (recommendations) has its own unique set of values. The fundamental difference between this process for medical use is the concept of the "best medical solution", in which the key role is given to the patient's state of health in obtaining and evaluating alternatives, as well as the need to take into account the time, adverse reactions of the body and the costs of implementing this solution. In the medical field, support for medical decision-making can be classified as organizational-managerial and therapeutic-diagnostic, but both are determined by the position of the person making the medical decision and are aimed at effective management of the medical institution as a whole. The article describes the causes and factors of the nature of uncertainty in the tasks of supporting medical decision-making in medical-diagnostic and organizational-managerial areas. The analysis of the features of supporting medical decision-making in conditions of uncertainty is carried out. Approaches and directions in this area, as well as the concept of “solution”, are considered. The essence of the management medical decision is reflected. The classification of management medical decisions is given, the requirements that are imposed on them are highlighted. The features of the development of management medical solutions in the conditions of incompleteness and uncertainty, the problems that arise when they are implemented in information systems are presented. The general scheme of the process of creating a management medical solution is shown. The features of making group and individual decisions are reflected. The algorithm of actions of the person making the medical decision in the conditions of uncertainty, incompleteness and risk in medical subject areas is presented.

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.

Reducing overuse by recognising the unintended harms of good intentions

2019 ◽  
pp. bmjebm-2019-111247
Author(s):  
David Slawson ◽  
Allen F Shaughnessy
Keyword(s):  
Decision Making ◽  
Medical Decision Making ◽  
Clinical Care ◽  
Critical Role ◽  
Medical Decision ◽  
Wide Acceptance ◽  
Hierarchy Of Evidence ◽  
Healthcare Interventions

Overdiagnosis and overtreatment—overuse—is gaining wide acceptance as a leading nosocomial intervention in medicine. Not only does overuse create anxiety and diminish patients’ quality of life, in some cases it causes harm to both patients and others not directly involved in clinical care. Reducing overuse begins with the recognition and acceptance of the potential for unintended harm of our best intentions. In this paper, we introduce five cases to illustrate where harm can occur as the result of well-intended healthcare interventions. With this insight, clinicians can learn to appreciate the critical role of probability-based, evidence-informed decision-making in medicine and the need to consider the outcomes for all who may be affected by their actions. Likewise, educators need to evolve medical education and medical decision-making so that it focuses on the hierarchy of evidence and that what ‘ought to work’, based on traditional pathophysiological, disease-focused reasoning, should be subordinate to what ‘does work’.

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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