Wednesday, July 7, 2010

When Capacity Is In Question

Let’s say your patient is in the earlier stages of dementia when a malignancy is discovered. Who decides his treatment options? Despite his dementia, it’s possible that it should be the patient himself.

Decision-making capacity is defined as “the patient’s ability to make his or her own decisions about accepting or rejecting medical procedures or treatments,” according to an article in the Journal of Palliative Medicine (November 2009). Author Frank Clore, a hospice spiritual care counselor, lists five considerations for the healthcare professional:
  1. Does the person understand the facts involved in making the decision?
  2. Does he “have an appreciation of the nature and importance of the decision to be made, including potential alternative choices?”
  3. Does he understand the benefits and risks of the decision?
  4. Can he communicate the decision to others, including the reasons for making the decision?
  5. Can he “deliberate based on consistent personal values?”
Clore suggests that you may be able to elicit the answers using these assessments:
  • Ask the patient to explain what he/she understands about his/her illness and about the proposed treatment.
  • Ask what the patient thinks about the proposed treatment, how it may help him/her, and what will happen if the treatment is not chosen.
  • Ask the patient to repeat his/her choice; answers should be consistent over time.
As with all patients, but especially those whose capacity for decision-making is in question, Clore reminds us the patient should be properly informed and free of coercion, and that the patient be “assessed in relationship to a specific decision, at a specific time, and in a specific context.”

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