Decision Making at the End of Life

• Pain• Fear• Depression (SI)• Isolation• Cognitive loss

• Ethics• Law• Role of Psychiatrist• Advance Directive• SHC Guidelines

Situations

• Rights of competent patient• Rights of incompetent patient

– Advance Directive– Surrogate– Guardian– Unrepresented

• Termination of life support – Vegetative / terminal vs. limited awareness (Schiavo case)– Competent, advance directive, or surrogate– Unrepresented– Guardian

Ethics

• Personal autonomy– Right to be left alone – Right to exercise prospective autonomy

• Respect for life• Substituted judgment• Best interest

Law

• Landmark Cases– Right to consent / refuse, right to die

• Health Care Decisions Law (2000)– Advance Directive

• SHC Guidelines– Protocols integrated medical custom and the law

Role of the Psychiatrist

• Independent assessment capacity / competency

• Write sufficient good consultation report

• Indicate if / how capacity can be restored

Psychiatric Assessment

• Ability to understand & knowingly / intelligently act upon consent information using rational processes.

• Determine by questioning patient and doing MSE.

• Are there mental status deficits that cause the impaired decision? – Assess level of alertness, information processing, thought

processes , ability to modulate mood and affect.

• Is the impairment substantial? Enduring? Treatable?

Advance Directive

• Exercise of prospective autonomy – Appoints agent– Specifies wishes agent is to carry out

• Do you really need one?– Best interests of another may rule– If court / guardian involved, see “Wendland.”

• If hospitalized, can easily appoint a surrogate

SHC Guidelines Online

• Adult patient with capacity• Adult patient lacks capacity but has advance

directive, surrogate, or conservator or person • Adult patient lacks capacity & has no surrogate

– Medical custom, second opinion, risk management, (Ethics Committee)

• If decision to withdraw life support, consider exclusions, refer Ethics Committee, COS, Court (patient Cs rejects)

– See review of law: Conservatorship of Wendland.