1. CONSENT, CAPACITY & MEDICAL DECISION MAKING B. Prystawa, MD FRCP (C) Geriatric Psychiatrist February 2015

2. DISCLOSURES None

7. OBJECTIVES 1)Understand the difference between consent, capacity and competency 2) Understand the 3 parameters of consent 3) Understand the 4 parameters of a capable decision

8. DOCTOR – PATIENT RELATIONSHIP Discipline ofControl of Own MedicineBody (Destiny)

9. WHO IS THE CAPTAIN OF THE SHIP? It is not in the stars to hold our destiny but in ourselves Shakespeare I am the Master of my fate, I am the Captain of my soul W.E. Henley With only fear and good judgement holding us back, we sailed out on the Northern Sea. With a boatload of crazy people, including the shotgun and me. Does anyone know how to drive this thing –”Santa Maria” Trooper

10. OPERATIONAL QUESTIONS What can I (not) do? What must I (not) do? What should I (not) do?

11. BASIC PRINCIPLES (MEDICAL ETHICS) Autonomy (personal liberty ) Beneficence (best interest standard ) Non-Maleficence (do no harm) Justice (do what is fair)

12. Consent ≠ Capacity ≠ Competency

13. Consent = process of permission

14. MARIA 78y caucasian widow of Italian heritage Lives alone in her own home Has 3 children – 1 daughter, 2sons – local Daughter brings her in to the office because of swelling and discoloration on her sternum O/E palpable mass in L breast

15. Born on Sicily – 3/8 children 2y education in Italian Immigrated after marriage - age 22 No formal education in English but learned “functional English” over the years Worked as a housekeeper in RC facility Always managed the household and $ No change in skill level

16. Where do we go from here?

17. DOCTOR – PATIENT RELATIONSHIP Discipline of Control of Medicine Destiny

18. MEDICAL CONSENT PROCESS THE PATIENT: Has adequate information (knowledge) Is made without coercion (free) Is able to make a decision (capacity)

19. KNOWLEDGE Explain Educate Clarify

20. MARIA Explain what you have found Provide education as to DDx and what needs to happen next to narrow down the possibilities Answer and questions

21. FREE Egocentric Autonomous

22. MARIA Explore her beliefs as to what the mass might mean Understand her wishes as to how to proceed Enquire as to whether she wants family involvement

23. Capacity

24. BASIC PRINCIPLES OF CAPACITY Task specific Situation specific Jurisdiction specific

25. PRESUMPTION OF CAPACITY

26. WHAT CAPACITY IS NOT NOT determined by committal status (except for psychiatric treatment in BC) NOT determined by diagnosis NOT agreement with the clinician NOT an MMSE score

27. WHY ARE CAPACITY ASSESSMENTS DONE? To assure persons, who are able, will be making essential choices for themselves. To protect those, who are not able, by substituting capable others to make the essential choices for them.

28. CAPACITY VS COMPETENCY CapacityCompetency M edical determinationLegal determination Clinical assessment Court process Recognizes “impaired” vs Usually “All or None” “preserved” function

29. WHAT IS A “CAPABLE DECISION”? 4 Parameters Understanding Appreciation Reason Communication/Choice

30. Understanding Has adequate knowledge of the pros, cons and the alternatives including doing nothing

31. Appreciation Is aware of the impact on oneself and others (family, care providers)

32. Demonstrates Reason Can demonstrate a logical thought process within the context of the information, their values and culture

33. Communication Relays a consistent choice

34. WHAT DOES THAT LOOK LIKE?

35. Understanding After disclosing the clinically relevant information the clinician asks the patient to repeat in their own words what was said to them

36. MARIA I have found a mass (lump) in your breast. Breast masses in a lady your age can be one of several things. They can be cancer or they can be benign. Something that is cancerous will grow, eventually spread and lead to worsening health and death. Something that is benign will not. To find out we need to do…

37. Appreciation The clinician ascertains how well the patient accepts that the facts presented actually apply to them by probing the patient’s beliefs about their diagnosis and about the possible benefits and risks of the treatment

38. MARIA Mammogram and FNA Single mass – Adenocarcinoma Meet with her and explain diagnosis. She seems to understand the concept of cancer and that it could be life threatening but does not want surgical intervention as “cutting it will make it spread”

39. MARIA Gives permission to speak with family. Daughter reports her mother has had the longstanding belief that cancer spreads by cutting. Folkloric belief from her village. As well, several family members with cancer had surgery and died of metastatic disease.

40. Reason The clinician assesses the patient’s ability to compare options, to infer how a particular choice will affect the them and the logical consistency of these answers

41. MARIA Referred to Cancer Clinic: 1) Do nothing 2) Local excision 3) Radiation therapy 4) Chemo/hormonal therapy Maria and dtr come to talk to you after the assessment and you review the recommendations.

42. Communication/Choice The clinician determines if the patient can communicate a consistent decision about the treatment

43. MARIA Decide no surgery but conservative approach.

44. MARIA Two weeks later, son calls demanding a meeting and insisting on a surgical referral as he’s the POA and its all “BS”. Now what?

45. MARIA Ask her what she wants to do

46. Document, Document