Slide 1

Slide 2 Determining Decisional Capacity in Hospitalized Patients Hospitalists Best Practices Conference July 16, 2010 J Rush Pierce Jr, MD, MPH Davin Quinn, MD Slide 3 Outline General Principles Lit review of available instruments Illustrative cases Legal requirements in New Mexico Discussion Adoption of instrument Role of psychiatry Role of neuropsych testing Consideration of template 2 Determining Decisional Capacity in Hospitalized Patients Hospitalists Best Practices Slide 4 Decisional Capacity General Principles Falls under the bioethical principle of autonomy Competency is different than decisional capacity Sliding scale More likely question if disagree with std recs Higher degree of competency required for higher risk 3 Determining Decisional Capacity in Hospitalized Patients Hospitalists Best Practices Slide 5 How do we make decisions? Presidents Commission for the Study of Ethical Problems in Medicine and Biomedical Behavior Research (1982) Set of values and goals Ability to communicate and to understand information Ability to reason and deliberate about ones choices 4 Determining Decisional Capacity in Hospitalized Patients Hospitalists Best Practices Slide 6 Functional abilities required to make decisions (consensus opinion) Express a choice Understand the information required to make a decision Appreciate how the information pertains to ones own life and circumstances Reason logically using the information presented 5 Determining Decisional Capacity in Hospitalized Patients Hospitalists Best Practices Slide 7 Literature review general Methodologic problem of the gold standard Many use consensus opinion regarding abilities required to make decision Most studies involve psychiatric patients or Alzheimers pts Types of studies (consent for medical treatment, research participation, various everyday tasks) 6 Determining Decisional Capacity in Hospitalized Patients Hospitalists Best Practices Slide 8 Consent to medical treatment specific clinical instruments Folstein MMSE Capacity to Consent to Treatment Instrument (CCTI) Hopemont Capacity Assessment Interview (HCAI) McArthur Competency Assessment Tool Treatment (MCAT-T) 7 Determining Decisional Capacity in Hospitalized Patients Hospitalists Best Practices Slide 9 Consent to medical treatment specific clinical instruments Folstein MMSE most useful in Alzheimers pts and at lower end of scale < 19 highly likely to be associated with decisional incapacity > 26 strongly assoc with decisional capacity not good at testing executive function Takes about 12 minutes 8 Determining Decisional Capacity in Hospitalized Patients Hospitalists Best Practices Slide 10 Consent to medical treatment specific clinical instruments CCTI Uses two clinical vignettes (cancer, CAD) Pt given two treatment options Uses structured interview to test capacity in the 4 areas Takes about 30 minutes HCAI Similar to CCTI (eye-infection, severe pneumonia) but also uses some day-to-day situations Similar structured interview Takes about 40 mins 9 Determining Decisional Capacity in Hospitalized Patients Hospitalists Best Practices Slide 11 MacArthur Competence Assessment Tool for Treatment (MCAT-T) Uses structured interview Incorporates information specific to a given situation Highest inter-rater reliability Requires training Takes about 20 minutes 10 Determining Decisional Capacity in Hospitalized Patients Hospitalists Best Practices Slide 12 Modified MCAT-T (NEJM. Appelbaum PS. Assessment of Patients Competence. NEJM 2007;357:1834-40) 11 Determining Decisional Capacity in Hospitalized Patients Hospitalists Best Practices Slide 13 How to Assess Capacity 4 crucial prongs: The patient must Express a consistent choice over time Understand the facts of the situation Appreciate the risks and benefits Use a rational thought process Sliding scale of sophistication Different kinds of decisions require different capacities 12 Determining Decisional Capacity in Hospitalized Patients Hospitalists Best Practices Slide 14 How to Assess Capacity Express a consistent choice over time No expression leads to a presumption of incapacity Does the patient have a condition impeding their ability to express a choice? (Aphasia, locked-in syndrome) How much time is over time? People can change their minds, based on new information Indecisiveness, or vacillation in the absence of new information, may indicate incapacity 13 Determining Decisional Capacity in Hospitalized Patients Hospitalists Best Practices Slide 15 Example #1: Choice 50 yo F ESRD on HD Schizophrenia Agree to dialysis, then refuse in HD unit 3x Repeated questioning about her vacillation revealed she had overwhelming, unrealistic fear about what would happen to her when in HD Decision went to surrogate 14 Determining Decisional Capacity in Hospitalized Patients Hospitalists Best Practices Slide 16 How to Assess Capacity Understand the facts of the situation Can pt take in (hear, read) the facts? Has pt been told the facts? Does pt remember the relevant information in his or her own terms? Does pt understand cause and effect relationships and probabilities in this situation? Does pt understand the role as decision-maker? 15 Determining Decisional Capacity in Hospitalized Patients Hospitalists Best Practices Slide 17 Example #2: Understand 40 yo M HIV/AIDS CD4 40 Pneumocystis pneumonia Wants to leave AMA Theres nothing wrong with me. Patient was found to be delirious, not allowed to leave Agreed to treatment 16 Determining Decisional Capacity in Hospitalized Patients Hospitalists Best Practices Slide 18 How to Assess Capacity Appreciate the risks and benefits of the choice Does pt have an awareness of the seriousness of the illness? Does pt appreciate the likely consequences of treatment or refusal? 17 Determining Decisional Capacity in Hospitalized Patients Hospitalists Best Practices Slide 19 Example #3: Appreciate 26 yo M DM, heavy ETOH abuser LE cellulitis requiring IV abx x 7 days ETOH withdrawal Wanted to leave AMA after 3 days I know if I dont get IV antibiotics, my infection could come back and I could die. I know I could have a seizure and die. I have to get home. Allowed to leave AMA 18 Determining Decisional Capacity in Hospitalized Patients Hospitalists Best Practices Slide 20 How to Assess Capacity Use a rational thought process Does pt weigh risks and benefits through a logical thought process? Does the conclusion flow logically and is consistent with starting premises and stated goals or values? Factors that may play a role: PsychosisDelirium DementiaPhobias PanicAnxiety DepressionMania AngerPersonality/coping style 19 Determining Decisional Capacity in Hospitalized Patients Hospitalists Best Practices Slide 21 Example #4: Rational 65 yo F Hx CAD, HTN, CHF, Major depressive disorder Admitted for chest pain, + troponins Refused cath Its my time. Ive lived a full life. Ive made my peace with death. Family: recent cholecystectomy, followed by increased sleep, fatigue, isolation, SI Surrogate contacted, cath obtained, psych admission 20 Determining Decisional Capacity in Hospitalized Patients Hospitalists Best Practices Slide 22 Sliding Scale of Sophistication Not all decisions are created equal Severity of consequences of a decision dictates the level of understanding/appreciation/rationality necessary to make it Refusing hangnail treatment does not require the same sophistication as refusing aortic dissection repair 21 Determining Decisional Capacity in Hospitalized Patients Hospitalists Best Practices Slide 23 Risk/Benefit Table Low Benefit High Benefit (capacity to refuse) Low RiskTube feedsIV antibiotics High Risk (capacity to accept) Experimental chemotherapy CABG 22 Determining Decisional Capacity in Hospitalized Patients Hospitalists Best Practices Slide 24 Capacity in New Mexico Uniform Health Care Decisions Act, July 1, 1995 Decisional Capacity: The ability to understand and appreciate the nature and consequences of proposed health care, including significant benefits, risks, and alternatives to proposed health care and to make and communicate an informed health care decision. Determination of incapacity requires two MDs, one of whom is the primary physician Suspected psychiatric/DD issues: need expert 23 Determining Decisional Capacity in Hospitalized Patients Hospitalists Best Practices Slide 25 Capacity in New Mexico Decision making goes to appointed surrogate (HCP) If no surrogate appointed/available, next in order: Spouse, unless separated, divorced, annulled Spousally committed person Adult child Parent Adult sibling Grandparent 24 Determining Decisional Capacity in Hospitalized Patients Hospitalists Best Practices Slide 26 Capacity in New Mexico If multiple members in decision making class: Agreementgood Disagreementmajority rules Evenly dividedthey and all lower classes disqualified No surrogates availablecourt appointed guardian If patient challenges incapacity determination: Challenge stands until court-order obtained 25 Determining Decisional Capacity in Hospitalized Patients Hospitalists Best Practices Slide 27 Standardized care at UNM Should we use the modified MCAT-T? Should the second physician be a resident, or always an attending? When should we call psychiatry? When should we order neuropsych testing? Draft template 26 Determining Decisional Capacity in Hospitalized Patients Hospitalists Best Practices Slide 28 27 Determining Decisional Capacity in Hospitalized Patients Hospitalists Best Practices