A 62-year-old woman has been admitted for the third time within 12 months for a severe COPD exacerbation requiring intensive care and mechanical ventilation. Currently she has been admitted for nine days without showing positive signs during weaning trials. Her other comorbid conditions, hypertension, CDK stage III, and dyslipidemia are well controlled. There is no evidence of another acute illness, such as pneumonia, UTI or another source of infection, and a CT scan did not reveal a pulmonary embolism. Her bloodwork has revealed a mild normocytic anemia and electrolytes that are within normal ranges. Her creatinine is 1.3 mg/dL which is at baseline. A discussion of the possible need for tracheostomy occurred yesterday, and she indicated that she was not ready to decide at that time.
Today she has made a decision. She wishes to completely withdraw respiratory support, including the current mechanical ventilation. She is able to communicate her wishes by writing. She has previously made good recoveries after her past admissions and had always indicated that she would want to be intubated again should her respiratory status indicate this need. There appear to be no symptoms of depression or signs of altered cognition. There is no advance directive, and her eldest son is the surrogate decision maker. Knowing that you believe she will likely die if mechanical ventilation is discontinued she writes to you now, “Will you please let me die naturally?”
Which of the following is the best next step in this patients care?
A. Attempt to persuade her to proceed with the tracheostomy instead.
B. Contact her surrogate decision maker to decide the next step.
C. Consult psychiatry to evaluate the patient’s mental status.
D. Evaluate the patient’s decision making capacity.
E. Declare the patient incompetent to make decisions due to her medical condition.
Correct answer:D – Evaluate the patient’s decision making capacity
Key Point: Decision making capacity can be determined by any physician after a brief evaluation of the patient. Once capacity is determined to be present, the patient is able to make any and all decisions regarding withholding of treatment, including decisions that lead to loss of life or limb.
Discussion:This question involves the concept of decision making capacity which frequently comes up in the ICU setting, usually involving patient decisions that make physicians uncomfortable. The global approach to a patient requesting unusual or drastic decisions is very broad and can be complex, but all physicians should be familiar with evaluating capacity.
There are essentially four points to consider when assessing capacity:
- An understanding of the information provided
- Communication of choice
- An appreciation of available options
- Rational decision-making.
If the patient is able to demonstrate these four standards then the patient may be considered to have capacity and at that point their wishes to withhold treatments may be carried out. Capacity is task-dependent. A patient may have capacity to refuse a blood transfusion but not to refuse a complex regimen of neoadjuvant chemotherapy and radiation. The following five questions can help during the evaluation:
- Will you explain the treatment we recommend?
- What is your understanding of how this treatment can help you?
- What is your understanding of what could happen if you do not receive this treatment?
- What alternatives would you choose instead to address the problem?
- Why have you decided to accept or refuse the treatment suggested?
Patients that refuse to participate in the conversation should be considered not to have capacity. It may be necessary to deny some patients their stated wishes in this situation. Involving the patient’s family, chaplain services, and the ethics committee can be essential in helping resolve these difficult situations.
Physicians should not attempt to persuade patients to make certain decisions but rather engage in informed consent and shared decision making as much as possible. Surrogate decision makers should be identified and present for the capacity evaluation if appropriate but should not be contacted to make decisions without evaluating patient capacity first. Psychiatry is often asked to determine capacity but any physician can make this determination. In addition, the patient’s mental status does not appear to be altered based on the question stem. Finally, declaring a patient incompetent is primarily a legal procedure performed by a judge, not a physician. All patients are assumed to have competence.
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