Presentation on theme: "COMPETENCY ISSUES AND DEMENTIA PMDA’s 16 th Annual Symposium October 24, 2008."— Presentation transcript:
COMPETENCY ISSUES AND DEMENTIA PMDA’s 16 th Annual Symposium October 24, 2008
Presenters Kenneth Brubaker, MD, CMD Geriatric Program Director Lancaster General Hospital Lancaster, PA Paula G. Sanders, Esquire Post & Schell PC 17 North 2 nd Street, 12 th Floor Harrisburg, PA
Objectives Define competency and decision- making capacity Identify ways to evaluate these abilities in patients with dementia Discuss implications for families and surrogates in making treatment decisions
What is Competency? “A threshold requirement, imposed by society, for an individual to retain decision making power in a particular activity or set of activities.” Daniel Marson, J.D., Ph.D.
Many Types of Capacity 1) Driving 2) Living 3) Financial 4) Medical 5) Testamentary
Physician Competency Judgments (%) Normal Controls [n=16]
Physician Competency Judgments (%) Mild AD Patients [n=29]
Capacity to Consent to Medical Treatment Autonomy vs. Protection/Safety
Conceptual Model Based on U.S. Case Law a. Ability to Understand b. Ability to Appreciate c. Ability to Reason d. Ability to Make a Choice
87 year old retired plumber who has mild dementia (MMSE 22) and type II DM Renal failure (GFR = 30) CAD (EF 30%) PVD (ABI of.3) Tissue necrosis of the right and left feet
What Options are Available for Treatment? 1) Keep comfortable 2) Vascular evaluation 3) Bilateral amputations
Ability to Understand Comprehend meaning of the information Repeat in your own words the facts.
Ability to Appreciate Recognize the facts apply to you Tell me in your own words what your medical problem is.
Ability to Choose Repeat in your own words what options are available. What is your choice and can consistently hold to the same choice.
Ability to Reason How will your choice affect you? Why have you eliminated the other choices?
Dealing with Conflict between POA, Resident, and Care-Giver a) Education b) Conflict Resolution (Ethics Committee)
Shivo case is an example of failed conflict resolution. Not all conflict can be reached with dysfunctional families. Occasionally courts will be needed for decision-making.
Tests Used for DMC 1) Capacity to Consent to Treatment Instrument (CCTI) Marson, et al, categories – capable, marginally capable, incapable 2) Assessment of Capacity for Everyday Decision Making (ACED) 3) Masonic Village tool
Act 169: Incompetent Unable to understand, make, and communicate health care decisions, even when provided appropriate information and aids. A resident may be competent to make some simple health care decisions, but incompetent to make complex decisions.
Act 169: Option for Health Care Agent (Health Care POA Document) Health Care Agent has very broad power to make health care decisions. Health Care Agent can make medical treatment decisions before or after the resident is diagnosed with an end stage medical condition or permanent unconsciousness.
Act 169: Option for Health Care Representative A resident of sound mind may appoint a Health Care Representative(s). The process is less formal. May be in writing or by verbal consent Health Care Representative may make decisions regarding life sustaining treatment only if the resident has an end stage medical condition or is permanently unconscious.
Act 169: Option for Default Health Care Representative An incompetent resident will have a Default Health Care Representative(s) automatically assigned to make medical treatment decisions. Health Care Representative may make life sustaining treatment decisions only if the principal has an end stage medical condition or is permanently unconscious.
Act 169: The Default Health Care Representative – Priority Class Spouse and adult child (children) from prior marriage Adult child (children) Parent(s) Adult sibling(s) Adult grandchild (grandchildren) Close friend(s)
How Are Health Care Representatives Assigned? Resident may assign or disqualify one or more Health Care Representatives to make treatment decisions Resident may adjust or alter the order of priority Someone from the priority list may step forward and state their intention to be the Health Care Representative
Dispute Resolution Among Health Care Representatives Follow decisions of highest priority decision-maker Decision-makers of equal priority must agree on the course of action Majority decision determines course of action
Dispute Resolution Among Health Care Representatives If priority class is evenly split: 1. No one else “votes” to break the tie 2. Ethics Committee involvement 3. Court hearing for appointment of Guardian of Person
Dispute Resolution Among Health Care Representatives Medical treatment according to acceptable standards of practice must be started or maintained until a dispute is resolved.
Documentation Issues What to write When to write How often to write
REFERENCES Marson et al., Cognitive models that predict physician judgments of capacity to consent to mild Alzheimer’s disease. JAGS 45, , 1997 Appelbaum,P.S.,Grisso,T. (1988) Assessing patients' capacities to consent to treatment. New England Journal of Medicine, 319, Marson,D.C., Ingram,K.K.et al (1995) Assessing the competency of patients with Alzheimer's disease under different legal standards. Archives of Neurology, 52, Moye,J.,Marson,D.C, Assessment of Decision-Making Capacity in Older Adults:An Emerging Area of Practice and Research. Psychological Sciences 2007, vol.628, No. 1, PA Act 169: +%26+Sections +%26+Sections