CONSENT, CAPACITY & MEDICAL DECISION MAKING B. Prystawa, MD FRCP (C) Geriatric Psychiatrist...

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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

Document, Document,

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