perils and pitfalls of the incapacitated patient providence health care
TRANSCRIPT
Perils and Pitfalls of the Incapacitated Patient
Andi Chatburn, DO, MALeanne Park, RN, JDJeremy Williams, RN
Mission As people of Providence, we reveal God’s love for all, especially the poor and vulnerable, through our compassionate service.
Vision Together, we answer the call of every person we serve: Know me, care for me, ease my way.®
Objectives
• Review essential elements of Informed Consent and when Implied Consent is sufficient
• Learn how to assess capacity in both emergency and routine situations
• Discover who can make decisions for the incapacitated patient
• Explore WA state laws and procedures related to Involuntary Treatment for Mental Health
• Learn appropriate applications of the Single Bed Certification and how it affects your practice
Psychiatric Terms
• DMHP- Designated Mental Health Professional
• Initial Detention• Grave Disability• Less Restrictive Alternative• Likelihood of serious harm
Autonomy
Capacity
Informed ConsentProcess
Implied Consent Emergency
Involuntary Treatment
Minors & Patients
with Guardians
Serio
us H
arm
Case of Mr. A
• 53 yo construction worker• Brought in by EMS after MVA • Unconscious, uncommunicative• Acute abdominal pain, hypotensive • Suspected abdominal bleeding and
potential for head injury• Emergency surgery recommended
Autonomy
Capacity
Informed ConsentProcess
Implied Consent Emergency
Involuntary Treatment
Minors & Patients
with Guardians
Serio
us H
arm
Implied Consent
Patient unable to express preference No surrogate available Acute- Immediate action required to: Save Life or Save Limb Reasonable person (non-experimental)
Perils & Pitfalls
• Whenever possible, 2 clinical providers should document severity and imminence of risk
• Implied consent ONLY applies to the procedure that is emergently necessary
• Less invasive temporary alternatives don’t exist
Application of Implied Consent
For Mr. A:
– YES: Exploratory laparotomy with splenectomy, craniotomy
–NO: PEG tube placement
Perils & Pitfalls
Implied consent cannot be used to justify a procedure if a
patient has previously refused
WA Surrogate Hierarchy
Guardian Durable Power of Attorney – HC Spouse or Registered Domestic Partner Adult Children Living Parents Adult Siblings
Case of Mr. A
• 53 yo construction worker• Admitted with dyspnea, fatigue and
recent history of a TBI• Found to have symptomatic bradycardia• Refusing recommended Implanted
Cardiac Monitor
Evaluation for Capacity
• Does Mr. A have the capacity to refuse recommended interventions?
• Any physician can make a determination of incapacity for medical decision making
?
Autonomy
Capacity
Informed ConsentProcess
Implied Consent Emergency
Involuntary Treatment
Minors & Patients
with Guardians
Serio
us H
arm
Autonomy
Capacity
Informed ConsentProcess
Implied Consent Emergency
Involuntary Treatment
Minors & Patients
with Guardians
Serio
us H
arm
Informed Consent
• Physician’s responsibility• Usually an ongoing discussion• Involves shared decision-making• Form is a written verification of the
process
Components of Informed Consent
• Nature and character of proposed treatment and procedures
• Anticipated results• Recognized possible alternatives• Recognized serious possible risks,
complications, and anticipated benefits–Proposed treatment–Alternatives
Capacity- Medical
Capacity is both specific and dynamic. Specific Question Specific Time Dynamic- can change based on time and
question
Appelbaum, P. Assessment of Patient’s Competence to Consent to Treatment. NEJM. 357; 18. 2007.
Pitfalls & Perils
• Clinicians regularly fail to recognize incapacity
• 2.8% of Healthy Elderly control patients in community lacked capacity
• 26% of Elderly Medicine Inpatients lacked capacity
• Physicians recognized incapacity only 42% of the time
Sessums, L. et al., Does this Patient Have Medical Decision-Making Capacity? JAMA 206; 4. 2011.
CURVES Mnemonic for Capacity
Choose & Communicate Understand Reason Value Emergency Surrogate
Chow, et al. CURVES: a mnemonic for determining medical decision-making capacity and providing emergency treatment in the acute setting. 2010 Feb; 137 (2): 421-7.
Perils & Pitfalls
• Risk of poor communication skills:–Pseudo-incapacity occurs when the patient
is provided information in a way they cannot understand.• Ex: excessive medical jargon
– English as Second Language–Patients who communicate nonverbally
Sessums, L. et al., Does this Patient Have Medical Decision-Making Capacity? JAMA 206; 4. 2011.
Additional Validated Tools
• Clock Drawing Test• ACE- Aid to Capacity Evaluation• MMSE <24/30 indicates delirium or dementia• MDAS (Memorial Delirium Assessment Scale)• MacArthur Competence Assessment Tool for
Treatment (MacCAT-T)• CAM- Confusion Assessment Scale
Sessums, L. et al., Does this Patient Have Medical Decision-Making Capacity? JAMA 206; 4. 2011.
Low Risk High Risk
Capacity Spectrum
• Less invasive• Less detailed• Less teach back
• More invasive • More detailed• Complex teach back
5 Questions Adapted, 6th grade level
1. What is going on with your body right now?2. What treatment is being recommended to you?3. What might happen to you if you decide to
accept that treatment?4. What might happen to you if you don’t have
that treatment?5. What alternative are available and what are the
consequences of each?
Appelbaum, P. Assessment of Patient’s Competence to Consent to Treatment. NEJM. 357; 18. 2007.
Informed Consent Policy
Refusal of interventions:Patients who have medical decision making capacity are allowed to be refuse recommended medical interventions and make what may seem like unreasonable or even harmful choices.
Soriano, M. and R. Lagman. When the Patient Says No. American Journal of Hospice & Palliative Medicine. 29(5) 401-404.
WA Surrogate Hierarchy
Guardian Durable Power of Attorney – HC Spouse or Registered Domestic Partner Adult Children Living Parents Adult Siblings
Case of Mr. A
• 53 yo construction worker• Recovering from TBI, now at SLRI• Acute Psychotic Episode• Long acting depot antipsychotic • Found to have Paranoid Schizophrenia• Persistently banging head against wall,
refusing ALL medications
Autonomy
Capacity
Informed ConsentProcess
Implied Consent Emergency
Involuntary Treatment
Minors & Patients
with Guardians
Serio
us H
arm
• The individual must have a treatable mental disorder • Presents a danger to self, others, or
property and/or• Is Gravely Disabled
Criteria for Civil Commitment
Grave Disability
• Danger of serious physical harm resulting from a failure to provide for his or her essential human needs of health or safety
OR• Manifests severe deterioration in routine
functioning evidenced by repeated and escalating loss of cognitive or volitional control over his or her actions and is not receiving such care as is essential for his or her health or safety.
• Once provider has suspicion of treatable mental illness that poses risk of imminent harm • Three (3) hours to call DMHP for
Involuntary Treatment Act evaluations
Steps to Call DMHPs
DMHP Evaluation
• Has twelve (12) hours to evaluate patient and make detainment decision
• If they decline to evaluate patient- ask name and let them know you will document declination in record
• If they evaluate and release patient, consider discharge
Involuntary Treatment
• Single Bed Cert (SBC) or Psychiatric Bed• If DHMP detains:–72 hour initial detention–Potential for 14 day +–Pertains to Psychiatric treatment ONLY
Perils & Pitfalls
• ITA detention permits involuntary treatment:–Psychiatric medications (with exceptions)–Psychiatric therapy/treatment–Detention in facility (cannot leave AMA)
Perils & Pitfalls
• ITA does not authorize any other medical care, intervention, or treatment–Must evaluate patient for decisional
capacity– If patient lacks capacity, must communicate
with surrogates to make medical decisions
Case of Mr. A- Part 4
• 53 yo construction worker• Hx TBI, Paranoid Schizophrenia• AICD placed due to arrhythmia• s/p splenectomy • Daughter now seeking placement and
asking “what happens next time he comes into the hospital?”
Autonomy
Capacity
Informed ConsentProcess
Implied Consent Emergency
Involuntary Treatment
Minors & Patients
with Guardians
Serio
us H
arm
Competence- Legal
Adults assumed competent Incompetence determined by a court Global- unable to make any decisions Need for referral to attorney with goal of
naming a Guardian ad Litem Guardian
PHC Resources
• Social Work–Assist in searching for surrogate decision
maker– Start process to obtain a guardian–Assist in consulting DMHPs for consults
outside the PSHMC ED–Assist in consulting Telepsych for patient with
a treatble mental illness in a medical bed
PHC Resources: After Hours
• Call Social Work first• If Social Work not available, call the
Nursing House Supervisor at your facility
PHC Resources- PSHMC ED
• Psychiatry Triage:–Assist in consulting DMHPs–Assist in consulting psychiatry for a patient
with treatable mental illness–Assist in determining capacity for a patient
whose mental illness is complicating capacity determination
PHC Resources
• Office of Legal Affairs & Risk Management: –Assist in questions of guardianship, ex:
reviewing guardianship papers for validity–Assist in situations of conflict between
decision makers
PHC Resources
• Ethics Consultation:–Assist in situations of conflict between
decision makers or patient–Assist in conflict between patient’s known
wishes and surrogate decision making–Assist in situations of surrogate request for
medically non-beneficial interventions
PHC Resources
• Palliative Care: –Assist in determining goals of care with
patient, surrogate –Assist in patient naming a surrogate–Assist in conflict between patient/family for
an individual with a potential life threatening illness
PHC Resources
• Spiritual Care–Assist in supporting patients and families in
distress• Emotional• Relational• Physical • Spiritual
–Assist in finding, naming or determining a surrogate decision maker
Questions?
• Andi Chatburn, DO, [email protected]
• Leanne Park, RN, [email protected]
• Jeremy Williams, RN, [email protected]