Ethics: Capacity, Directives, and Confidentiality

What is capacity?

- medical term

- the person ability to make an informed decision

- assessed by a physician

- can change with the decision at hand

What is compentency?

- legal term

- the dress of mental soundness to a specific decision about a specific issue

- assessed by a judge

- typically doesn't change

Why is capacity important in medical ethics?

- respects a patient's autonomy

- if a patient has capacity, their autonomy must be respected

- If not, the provider must act with beneficence

What are the four components to assess capacity?

1. Understanding (does the patient understand the information being disclosed along with the risks and benefits)

2. Appreciation (ability to apply relevant information about the patient's own situation)

3. Reasoning

4. Expression of choice (can they communicate their decision)

What does the acronym iCURVES stand for in assessing capacity?

- Informed: has the patient received all pertinent information regarding illness

- Choose and communicate: patient can choose and communicate their decision

- Understand: patient appreciates and understand the severity of illness

- Reason: patient can explain decision in a logical and linear fashion

- Value: is the patient consistent with their choice

- Emergency: impeding risk to patient

- Surrogate: is a decision maker readily available

A 33-year-old female is admitted for bipolar II disorder to the inpatient psychiatric department. During her admission she asks to be placed on birth control. Prior to her admission, the courts have deemed the patient to lack competency. Her spouse is her next of kin and medical power of attorney. Her spouse does not want the patient on birth control. What should you do?

the legal system should layout what she has been deemed non-competent for --> if it's not medical decisions, then use iCURVES

Can a psychiatric history automatically determine a patient's capacity?

- No, a psychiatric history does not mean the patient lacks capacity

- each case must be assessed individually

When is a patient automatically deemed to lack capacity?

active suicidal patients

A 54-year-old female admitted to the hospital in DKA is found to lack capacity in the ED. When can she regain her capacity?

At anytime during her admission

2 multiple choice options

A 72-year-old man is diagnosed with colon cancer. He is in your office and verbally states he does not want any surgery for tumor removal. He also writes this down on paper and gives it to you. His wife, daughter and grandson are not in agreement with his plan. 5 months later the patient clinically declines and is taken to the hospital. He has a complete obstruction of the large bowel because of the tumor. On admission, he is deemed to have an altered mental status. He has lost capacity to make his medical decisions at this time. The family is now requesting a colectomy to be done. You:

Follow the advance directives and do not perform surgery

3 multiple choice options

What happens when your patient cannot make their own decision?

- look for advanced healthcare directives (someone with medical power of attorney)

- living will

- next of kin (spouse --> adult children --> parents etc)

Wanda is a 73-year-old brought to the ED by family after being found unresponsive. In the ED she was found to be in sepsis secondary to an obstructive ureteral stone and needs to have an invasive procedure by urology relieve the obstruction. The medical power of attorney was asked to make a clinical decision on whether or not to proceed with the procedure. How should the mPOA make his/her decision?

What would the patient want?

3 multiple choice options

Wanda is a 73-year-old brought to the ED by family after being found unresponsive. In the ED she was found to be in sepsis secondary to an obstructive ureteral stone and needs to have an invasive procedure by urology relieve the obstruction. The patient's husband believes she would not want the procedure, but her three adult children and Wanda's sister said she would want the procedure. Who should make the decision?

The patient's husband

3 multiple choice options

Wanda is a 73-year-old brought to the ED by family after being found unresponsive. In the ED she was found to be in sepsis secondary to an obstructive ureteral stone and needs to have an invasive procedure by urology to relieve the obstruction. The patient's husband believes she would not want the procedure, but her three adult children and Wanda's sister said she would want the procedure. All parties are present in the patient's room. What should the provider do?

Conduct a meeting between the disagreeing parties

2 multiple choice options

What are advanced directives?

- documents that direct medical care of the patient, and/or name a surrogate to make decisions, if the patient is unable to do so

- allows a patient to make legally valid decision about their own future medical care

What are the goals of advanced care planning?

1. Minimize burden of mPOA

2. Reduce conflict

3. Minimize over or under treatment

4. Maximize that the patient's goals would be met

When do advance directives go into effect?

When the patient loses capacity

What is Physician Orders for Life-Sustaining Treatment (POLST)?

A form that helps guide patient care through end-of-life treatment plans

Is a POLST an advanced directive?

No, its additional

What is a Do Not Attempt Resuscitation (DNAR)?

written by the attending physician with a patient or surrogate decision maker that indicates whether the patient will receive CPR in the setting of cardiac and/or respiratory arrest

What is the order of surrogacy in PA?

1. spouse

2. all other adult children

3. parents

4. adult brothers and sisters

5. adult grandchildren

6. other adults who know your preferences and values

How do you break bad news?

- become comfortable, be calm, be ready

- The more you know, the more information you can give a patient

- you will become less stressed about giving bad news

What is SPIKES, for giving bad news?

1 .Setting up the interview

2. Assessing the patient’s Perception

3. Obtaining the patient’s Invitation

4. Giving Knowledge and information to the patient

5. Addressing the patient Emotions with empathic responses

6. Strategy and summary

What are impaired providers?

behavior that is putting the patient at risk or in danger (alcoholism, substance abuse, psychiatric and medical illness, alzhimer's etc)

What are concerns ab ot intervening with impaired providers?

- uncertainty whether patients are at serious risk

- Reluctance to criticize colleagues

- Retaliation against whistleblowers

You are part of the cardiology team and have been working in that department for 7 years. Over the past few months, you start to detect signs of dementia from your supervising physician. Examples include finding her wandering the halls not able to find the patient rooms, ordering improver imaging and medications, and becoming very short and aggressive if put in pressured situations. What should you do?

Tell your supervisor

3 multiple choice options

What is duty to confidentiality?

patient need to be able to trust providers will protect any information that is shared with them in confidence

When should providers break confidentiality?

- the patient is going to harm himself/herself

- the patient has a clear intent and plan to harm another individual

A 66-year-old male presented to the ED with sudden onset right eye blindness and severe uncontrolled headaches. The patient is A&O x 3. A CT revealed a large brain tumor. While waiting for the patient to return from the CT, his wife approaches you and asks for the results. She shows you her identification which matches his chart records as his wife. What should you do?

Only give the information to the patient

3 multiple choice options

A 44-year-old female was brought to the ED after being in an MVA. She caused a head on collision involving the opposite car with a driver (28-year-old male) and 2 children, 8 and 3 years of age. The driver and two passengers did not survive the accident. During her ED evaluation the driver's BAL was above the legal limit. The local police department is in the ED and has requested the records for full documentation. What do you do?

Do not give the records

3 multiple choice options

What are the reason for confidentiality?

- Shows respect for the patient

- Encourages people to seek medical care and discuss sensitive issues candidly

- prevents harmful consequences to patients

What is a providers duty regarding medical errors?

- providers have a duty to inform patients of errors

- It is always best to tell the patient the error was made and if the error will (or will not) impact the management or treatment plan