Evaluating Decision Making Capacity Essay Assignment

Evaluating Decision Making Capacity Essay Assignment

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Goal: The goal of this assignment is to introduce you to the essential components of evaluating decision-making capacity (DMC) in patients, and to provide you with opportunities to practice your understanding of these principles through sample cases.

Educational Objectives:

Students will be able to identify the 4 criteria that must be met for decision-making capacity to be deemed intact.
Students will be able to apply these criteria to determine whether decision-making capacity is present or absent in sample cases.

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Conceptual Background and Rationale for Curriculum:

Evaluation of decision-making capacity (DMC) is a clinical challenge faced by many mental health providers. Questions regarding capacity commonly arise in numerous specialties, including internal medicine, obstetrics/gynecology, surgery, and neurology. Requests for a detailed capacity evaluation may be directed to consultants in psychiatry. The goal of this curriculum is to help you learn the concepts and skills necessary to perform a capacity evaluation that is both efficient and sufficiently comprehensive.

Step 1: Read the attached file “Evaluating DMC – A Primer on Concepts”

Step 2: Choose 1 case from the attached document “Evaluating DMC–Cases”

– There are four generally accepted criteria that a patient must meet for decision-making capacity to be deemed intact:
1. Ability to understand the pertinent medical information
2. Ability to appreciate one’s situation and potential outcomes or consequences
3. Ability to arrive at a decision through reasoning
4. Ability to communicate a choice Evaluating Decision Making Capacity Essay Assignment

Given that decision-making capacity can fluctuate over time, these four elements need to be assessed on an ongoing basis.

Step 3: Using the 4 criteria from the reading above as the basis for your discussion of decision-making capacity, choose one of the cases and answer the questions posed on your chosen case from the list of cases in the document above.  Support your responses with examples from the case. ***USE the attached document labeled ”Response Template” to formulate your response to one of the scenarios.

Scenario: Mr. J, a 49-year-old man with ESRD, hypertension and diabetes who is admitted to the medicine service with a necrotic left foot with maggots in the wound.

Based on the information provided in the chosen scenario, does it appear the patient has decision-making capacity?

On the basis of the facts given, it is unsure if Mr. J has the ability to make this decision.

Apply each of the 4 criteria to formulate your response and give examples from the scenario to support your decision.

1. Ability to understand the pertinent medical information:

If Mr. J comprehends the important medical information, it’s uncertain. He repeatedly declined to have his leg amputated, but it is unknown why he did so or whether he truly understood the potential consequences of doing so.

1. Ability to appreciate one’s situation and potential outcomes or consequences:

The rotting left foot with maggots and the requirement for a bilateral amputation suggest that Mr. J may not completely understand his condition and the possible results or repercussions of forgoing the procedure. Concerns are raised about his capacity to understand the seriousness of his predicament given his refusal to have his leg amputated in spite of these circumstances.

1. Ability to arrive at a decision through reasoning:

It is uncertain whether Mr. J can make a judgment using logic. He has a flat affect and, according to his sister, may have a history of schizophrenia, which could impair his capacity for sound reasoning.

1. Ability to communicate a choice:

Mr. J’s ability to effectively convey a choice is in question. He frequently reacts to inquiries by averting his gaze and turning away, which can suggest a lack of interest or a poor capacity to communicate.

What other information would you need, if any, to be certain that you have considered all the possibilities?

Mr. J’s medical history, including any previous schizophrenia or other psychiatric condition diagnoses, as well as a complete mental status examination to gauge his capacity for making decisions are other pieces of information that might be useful.

What would you do next?

Given the ambiguity surrounding Mr. J’s competence for making decisions, a complete assessment by a psychiatrist or psychologist should be taken into consideration. Additionally, it could be important to speak with an ethical committee to assess the advantages and disadvantages of moving forward with or without Mr. J’s permission. As they may be familiar with his medical background and capacity for decision-making, Mr. J’s family should be included in the decision-making process. Finally, if Mr. J has the capacity to make decisions for himself, it may be necessary to involve legal authorities to guarantee that his rights are upheld and that the right choices are made on his behalf. Evaluating Decision Making Capacity Essay Assignment

Evaluating Decision-Making Capacity: Cases

Case 1

Mr S is a 37-year-old male with mild intellectual disability admitted for treatment with IV antibiotics for cellulitis. He lives independently and works part-time stocking shelves at a local retail store. Prior to completing his IV antibiotic course, he demands to leave the hospital. When asked why he wants to leave, he expresses frustration at the length of his hospital stay, states that he has mail and bills piling up at home, that his cat is alone, and that he wants to get out of the hospital in time to buy a birthday present for his nephew.

When reminded that his medical care team recommended that he stay for an additional two days to complete his antibiotic course, he states “But I feel fine. My energy is great, I don’t have a fever, and it doesn’t hurt that much at all. I’m fine. Besides, I really need to get home – there’s a lot to do. I just need to get this thing out of my arm [gestures to the IV], then I’ll call a cab and head home.” Evaluating Decision Making Capacity Essay Assignment

Based on the information you have so far, does it appear that Mr. S has decision-making capacity to leave the hospital AMA?

What data did you use to make your decision?

What other information would you need, if any, to be certain that you have considered all the possibilities?

What would you do next?

Case 2

Mrs. R is a 68-year-old retired nurse who formerly worked in the ICU. She has recently been admitted to the hospital for altered mental status and a fever. The ED team is in the process of working up her illness, and a nurse has just gone to her room to obtain a straight cath urine specimen, as the patient was unable to provide one voluntarily. Suddenly, a clatter and shouts emanate from her room – she has turned over her tray and has thrown her blankets to the floor. She yells “Get that catheter away from me!” and orders the nurse from her room.

When the medical student assigned to her care re-enters her room, she is found crouching in the corner, wearing only a hospital gown. She is plucking tissues out of a tissue box one by one and arranging them in a pile on the floor. When the medical student announces her presence by saying “Excuse me, Mrs. R. . . .?,” the patient looks up and replies “Oh, hi, honey. I’m so glad to see you. That witch was saying I might have a UTI. I don’t have a UTI! I’m a nurse, and I know I don’t have a UTI.  This isn’t even a real hospital!  Be quiet, quick, come over here.  If we just wait long enough, they’ll stop paying attention and we can sneak out.”

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Based on the information that you have, does it appear that Mrs. R has decision-making capacity to refuse the catheter?

What data did you use to make your decision?

What other information would you need, if any, to be certain that you have considered all the possibilities?

What would your next steps be? Evaluating Decision Making Capacity Essay Assignment

 Case 3

Mr. B is a 50-year-old married father of two, with a history of colon cancer, admitted to the hospital for evaluation and management of weakness, fatigue, and pre-syncopal episodes. Although his colon cancer had been treated to apparent remission with surgical resection and chemotherapy several years prior, medical work-up on this admission reveals significant anemia, presence of a mass at the site of his previous resection, and likely metastases to the liver. Following his work-up and a blood transfusion, he is informed by his care team of the recurrence of his colon cancer. The treatment team recommends repeat surgery to resect the new colonic mass, as well as adjunctive chemotherapy.

While not expected to drive his cancer into remission, it is anticipated that treatment as recommended would likely prolong life for 1-2 years. Without treatment, prognosis is much more guarded, although the team does note that it will be difficult to determine an exact prognosis without additional information, including further assessment of the recurrent mass through surgery and evaluation by pathology.

The following day on rounds, Mr. B tells his team that he does not want to pursue the recommendations for surgery and chemotherapy. He states “I’ve thought this over. The recovery from surgery, and then the chemotherapy. . .  . It was awful last time. I couldn’t do anything. I couldn’t be the person I wanted to be with my wife and kids because I felt so awful. I can’t do that again. I just want to let this pursue its natural course and spend as much time with my family as I can, while I still can.”

 Does Mr. B appear to have the decision-making capacity necessary to make this decision?

What data did you use to make your decision?

What other information would you need, if any, to be certain that you have considered all the possibilities?

What would you do next? Evaluating Decision Making Capacity Essay Assignment

Case 4:

Mr. C is a 70-year-old widower. His wife died two years ago and he has a daughter and three sons. His relationship with his children is marked by considerable conflict. He was recently hospitalized with gangrene in his right foot and lower leg. Problems with his foot began three years ago when he had an infection in the toe on his right foot which became gangrenous. It was then that he discovered that he was diabetic. The toe was amputated. Last year, he bruised his right leg while getting into a bus. The bruise developed into gangrene which resulted in an operation six months ago where a portion of his foot was amputated.  At that time an arterial bypass was done to decrease the likelihood that gangrene would recur. He went from the hospital to a rehabilitation center, where he remained for five months.  It was found that he had gangrene in the remainder of the foot.  He was started on intravenous antibiotics with no response. A below the knee amputation was suggested to him.

On the morning of the operation, he withdrew his consent and went home to stay with his daughter for three days. He has now been brought back to the hospital by his daughter.  Mr. C has been unhappy since the death of his wife.  He does not wish to burden his children, and he does not believe the operation will cure him.

Does Mr. C appear to have the decision-making capacity necessary to make this decision?

What data did you use to make your decision?

What other information would you need, if any, to be certain that you have considered all the possibilities?

What would you do next? Evaluating Decision Making Capacity Essay Assignment

Case 5

A 49-year-old man, Mr. J,  with ESRD, hypertension and diabetes is admitted to the medicine service with a necrotic left foot with maggots in the wound. He presented 5 months earlier with a nonhealing foot ulcer; numerous attempts were made to do vascular studies in preparation for revascularization or amputation, but he either directly refused or ate right before the procedure.  He was discharged with PO antibiotics at that time. He then went to live with family in another state; the ulcer progressed and he was admitted to a hospital there and told he needed bilateral LE amputations. He refused amputation multiple times and traveled to the ER complaining of pain in his legs as well as odor and discoloration of his foot.  Vascular is consulted for amputation. You order NPO after midnight for surgery the next day, but when you come in you read the following note from the Vascular intern:

“ASSESSMENT / PLAN: 49 yo M with ESRD on HD and dry gangrene on left foot. He refuses consent for a left leg open guillotine amputation x 2, saying “in a couple of days.” I explained to the patient the risk that he is taking if he doesn’t have the surgery. He appears to understand.”

You go to examine the patient. His mental status exam is notable for a flat affect. When you ask him a question, he will often respond by closing his eyes and turning away from you. He carries no psychiatric diagnosis in our records, but when you ask his sister she says “he’s never been right in the head” and thinks he was diagnosed with schizophrenia at some point in the past.

Scenario from Susan Merel, MD (2007) Evaluating Decision Making Capacity Essay Assignment

Does Mr. J appear to have the decision-making capacity necessary to make this decision?

What data did you use to make your decision?

What other information would you need, if any, to be certain that you have considered all the possibilities?

What would you do next?

Case 6

A 73-year-old man, Mr. P.,  with mild dementia comes for clinical follow-up with his daughter. Previously, he had stopped working as a salesperson due to his dementia and stopped driving due to cataracts, but had no other impairment in his activities of daily living (ADL’s). His daughter expresses concern about his ability to maintain his finances. He missed paying several bills in the last 3 months. Moreover, when out to dinner last week he had significant difficulty paying the bill. He recently invested in a dubious real-estate venture after talking with a telemarketer on the phone. When confronted, he denies that there are any problems with his ability to manage his finances.

The patient presented to the clinic, where he was found to have significantly impaired short-term memory. He could only perform one calculation correctly on serial 7’s, and had difficulty copying a cube. At the end of the interview, he asked several questions again that had been answered near the beginning of the interview. On behavioral interview, he could not reason through common financial situations, although he lacked an awareness of this impairment. An FDG-PET scan showed hypometabolism of the parietal and temporal lobes, consistent with a diagnosis of Alzheimer’s Disease.

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On more formal neuropsychological testing, he had mild executive function deficits, as well as specific deficits in arithmetic. He performed poorly on a financial capacity task, and demonstrated little awareness of his deficits. He was able to identify his daughter as his durable power of attorney and healthcare proxy, clearly describing what this entailed, as well as other options he had regarding this decision.

Does Mr. P appear to have the decision-making capacity necessary to continueto manage his own finances?

What data did you use to make your decision?

What other information would you need, if any, to be certain that you have considered all the possibilities?

What would you do next? Evaluating Decision Making Capacity Essay Assignment