CONSENT, CAPACITY & MEDICAL DECISION MAKING B. Prystawa, MD FRCP (C) Geriatric Psychiatrist February...
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Transcript of CONSENT, CAPACITY & MEDICAL DECISION MAKING B. Prystawa, MD FRCP (C) Geriatric Psychiatrist February...
CONSENT, C
APACIT
Y &
MED
ICAL
DEC
ISIO
N MAKIN
G
B. Prystawa, MD FRCP (C)Geriatric Psychiatrist February 2015
DISCLOSURES
None
OBJECTIVES1) Understand the difference
between consent, capacity and competency
2) Understand the 3 parameters of consent
3) Understand the 4 parameters of a capable decision
DOCTOR – PATIENT RELATIONSHIP
Discipline of Control of Own
Medicine Body (Destiny)
WHO IS THE CAPTAIN OF THE SHIP?
It is not in the stars to hold our destiny but in ourselves Shakespeare
I am the Master of my fate, I am the Captain of my soul
W.E. Henley
With only fear and good judgement holding us back, we sailed out on the Northern Sea. With a boatload of crazy people, including the shotgun and me.
Does anyone know how to drive this thing –”Santa Maria”
Trooper
OPERATIONAL QUESTIONS
What can I (not) do?
What must I (not) do?
What should I (not) do?
BASIC PRINCIPLES (MEDICAL ETHICS)
Autonomy (personal liberty)
Beneficence (best interest standard)
Non-Maleficence (do no harm)
Justice (do what is fair)
Consent ≠ Capacity ≠ Competency
Consent = process of permission
MARIA
78y caucasian widow of Italian heritage
Lives alone in her own home
Has 3 children – 1 daughter, 2sons – local
Daughter brings her in to the office because of swelling and discoloration on her sternum
O/E palpable mass in L breast
Born on Sicily – 3/8 children
2y education in Italian
Immigrated after marriage - age 22
No formal education in English but learned “functional English” over the years
Worked as a housekeeper in RC facility
Always managed the household and $
No change in skill level
Where do we go from here?
DOCTOR – PATIENT RELATIONSHIP
Discipline of Control of
Medicine Destiny
MEDICAL CONSENT PROCESS
THE PATIENT:
Has adequate information (knowledge)Is made without coercion (free)Is able to make a decision (capacity)
KNOWLEDGE
Explain
Educate
Clarify
MARIA
Explain what you have found
Provide education as to DDx and what needs to happen next to narrow down the possibilities
Answer and questions
FREE
Egocentric
Autonomous
MARIA
Explore her beliefs as to what the mass might mean
Understand her wishes as to how to proceed
Enquire as to whether she wants family involvement
Capacity
BASIC PRINCIPLES OF CAPACITY
Task specific
Situation specific
Jurisdiction specific
PRESUMPTION OF CAPACITY
WHAT CAPACITY IS NOT
NOT determined by committal status
(except for psychiatric treatment in BC)
NOT determined by diagnosis
NOT agreement with the clinician
NOT an MMSE score
WHY ARE CAPACITY ASSESSMENTS DONE?
To assure persons, who are able, will be making essential choices for themselves.
To protect those, who are not able, by substituting capable others to make the essential choices for them.
CAPACITY VS COMPETENCY
Capacity Competency
Medical determination Legal determination
Clinical assessment Court process
Recognizes “impaired” vs Usually “All or None”
“preserved” function
WHAT IS A “CAPABLE DECISION”?
4 ParametersUnderstandingAppreciationReasonCommunication/Choice
Understanding
Has adequate knowledge of the pros, cons and the alternatives including doing nothing
Appreciation Is aware of the impact on oneself and others (family, care providers)
Demonstrates Reason
Can demonstrate a logical thought process within the context of the information, their values and culture
Communication
Relays a consistent choice
WHAT DOES THAT LOOK LIKE?
UnderstandingAfter disclosing the clinically relevant information the clinician asks the patient to repeat in their own words what was said to them
MARIA
I have found a mass (lump) in your breast.
Breast masses in a lady your age can be one of several things. They can be cancer or they can be benign.
Something that is cancerous will grow, eventually spread and lead to worsening health and death. Something that is benign will not.
To find out we need to do…
AppreciationThe clinician ascertains how well the patient accepts that the facts presented actually apply to them by probing the patient’s beliefs about their diagnosis and about the possible benefits and risks of the treatment
MARIAMammogram and FNA
Single mass – Adenocarcinoma
Meet with her and explain diagnosis.
She seems to understand the concept of cancer and that it could be life threatening but does not want surgical intervention as “cutting it will make it spread”
MARIA
Gives permission to speak with family.
Daughter reports her mother has had the longstanding belief that cancer spreads by cutting. Folkloric belief from her village. As well, several family members with cancer had surgery and died of metastatic disease.
Reason
The clinician assesses the patient’s ability to compare options, to infer how a particular choice will affect the them and the logical consistency of these answers
MARIA
Referred to Cancer Clinic:
1) Do nothing
2) Local excision
3) Radiation therapy
4) Chemo/hormonal therapy
Maria and dtr come to talk to you after the assessment and you review the recommendations.
Communication/Choice
The clinician determines if the patient can communicate a consistent decision about the treatment
MARIA
Decide no surgery but conservative approach.
MARIA
Two weeks later, son calls demanding a meeting and insisting on a surgical referral as he’s the POA and its all “BS”.
Now what?
MARIA
Ask her what she wants to do
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