Miscellaneous: Decision Making

Decision Making Capacity

• Factors:
  • Clearly Communicate a Decision
  • Able to Describe Risks & Benefits
  • Able to Describe Consequences of Each Choice
• Cognitive Impairment Not Necessarily an Absolute Inhibition to Capacity

Advanced Directive

• Legal Documents that Indicate Decisions Regarding Care & End-of-Life Choices
• Highest Authority
• Types:
  • Formal Advanced Directive: Written Statements (Living Will, Power of Attorney (POA), DNR Orders)
  • Informal Advanced Directive: Verbal Statements to Family & Friends

Surrogate Decision Maker Hierarchy

• Durable Power of Attorney (POA) is First
• If No POA Designated: Spouse > Adult Child > Parent > Sibling > Guardian > Anyone Else
  • Spouse Includes Long Time Life Partner
  • Not Spouse if Divorced or Legally Separated
  • Anyone Else Can Include Distant Relatives & Close Friends
• Disagreements:
  • If Family Members Disagree: Family Meeting
  • If Still Disagree After Meeting: Ethics Committee

Decision Making if No Family or Legal Documentation Available

• Nonurgent: Ethics Consult
• Urgent: Second Physician Opinion
• Emergent: Implied Consent

Exceptions to Informed Consent

• Legal Incompetence – Patient Lacks Decision Making Capacity
• Emergent Situation – Implied Consent Given Medical Emergency or Life-Threatening Situation
• Therapeutic Privilege – Disclosure Would Cause Immediate Serious Harm or Would Seriously Undermine the Capacity for Decision Making
• Waiver – Patient Explicitly Waives the Right of Informed Consent

Pediatric Considerations

• “Assent” – Process by Which Pediatric Patients are Involved in Decision Making Although Consent is Still from Parents
• Physicians are Obligated to Act in Best Interest of Child; Even if Overriding Parents
• Family Jehovah’s Witnesses & Refusing Blood for Child
  • Emergent: Transfuse
  • Planned Elective Procedure That May Require Blood: Seek Court Order