Decision-Making Adam Burrows, MD Boston University Geriatrics Section Copyright Boston University Medical Center

Ethical Principles Autonomy –vs. Paternalism –Informed Consent Beneficence Nonmaleficence Justice

Informed Consent Nature of Problem Proposed Intervention Alternative Approaches Risks & Benefits

Decision-Making Capacity Decision-Specific Meet Standard of Informed Consent Standard Proportional to Risk –High Risk – High Standard –Low Risk – Low Standard

Assessing Capacity Can the Patient Give Informed Consent? –Expresses Appreciation of Situation –Understands Consequences of Decision Risks & Benefits –Manipulates Information –Reasons Coherently –Paraphrases

Who Assesses Capacity? Treating Clinician Consultant –Psychiatrist –Geriatrician When to Request Consult –Uncertainty –Conflict

Advanced Directives Goal –Protect Autonomy When The Patient Lacks Capacity Approaches –Surrogate Decision-Makers –Decision-Specific Documents

Surrogate Decision-Makers Durable Power of Attorney for Health Care Massachusetts Health Care Proxy Law Patient Self-Determination Act of 1990 Legal Guardian

Decision-Specific Documents Living Wills Health Wishes –Resuscitation –Mechanical Ventilation –Feeding Tube –Hospitalization Massachusetts Comfort Care Form

Surrogate Decision-Making Framing the Question –Substituted Judgment What would Mary choose if she could decide for herself? –Best Interest What do you think is best for Mary? Advantages of Substituted Judgment –Respects Autonomy –Reduces Burden on Surrogate

Decisions in Everyday Geriatrics Medical Interventions Long-Term Care Options –Home and Community-Based Care vs. –Nursing Home Managing Financial Affairs

Justice & Rationing Definition of Rationing –Withholding Care to Benefit Someone Else Locus of Rationing –Sometimes Appropriate Population Level Policy Decision –Never Appropriate Patient Level Clinical Decision