1. Good Help to Those in Need. ® BON SECOURS VIRGINIA HEALTH SYSTEM Guardianship and Patients Who Make Poor Decisions ACMA Virginia Chapter Spring Conference March 14, 2015 Nicholas Setliff, PhDc Bon Secours Virginia Health System

2. Good Help to Those in Need. ® BON SECOURS VIRGINIA HEALTH SYSTEM Overview of the Presentation Presentation of the case Topics of Concern Patient Autonomy Ethical Analysis Questions

3. Good Help to Those in Need. ® BON SECOURS VIRGINIA HEALTH SYSTEM Overview of the Case Mr. V is a 61yo patient who presented to the ED complaining of urinary frequency, chest pain, and epigastric pain. This is his second trip to the ED for these symptoms in two weeks. Mr. V has multiple chronic conditions including: diabetes, hypertension, and anxiety/depression.

4. Good Help to Those in Need. ® BON SECOURS VIRGINIA HEALTH SYSTEM Overview of the Case He has a history of MI with stent placement, prostate cancer with prostatectomy, and is found this admission to have a hernia. He lives in a hotel and according to the managers keeps mostly to himself and always pays his bills on time.

5. Good Help to Those in Need. ® BON SECOURS VIRGINIA HEALTH SYSTEM Overview of the Case Mr. V makes terrible medical decisions. His chronic conditions are all unmanaged. When asked why he does not take better care of himself, he reports that he cannot afford his medications. He does not fill prescriptions, despite being given vouchers and offers of help.

6. Good Help to Those in Need. ® BON SECOURS VIRGINIA HEALTH SYSTEM Overview of the Case Despite not managing his conditions, he is relatively well aware of his situation and consistently checks to be sure his hernia surgery will go ahead. He can converse clearly about his problems and concerns and asks about his treatment plan.

7. Good Help to Those in Need. ® BON SECOURS VIRGINIA HEALTH SYSTEM Overview of the Case After many refusals to accept help from the team to manage his conditions and to provide him with some form of home health, Mr. V earned a psych evaluation for competency.

8. Good Help to Those in Need. ® BON SECOURS VIRGINIA HEALTH SYSTEM Overview of the Case Psych determined that Mr. V would be best served in a setting where consistent care could be provided for his chronic conditions, as he was at high risk for rapid deterioration. Psych recommended either discharging him to a group home setting if he would agree, or pursuing guardianship if he would not. Mr. V refused to go to a group home since they would not provide television.

9. Good Help to Those in Need. ® BON SECOURS VIRGINIA HEALTH SYSTEM Overview of the Case Psych asked the case manager to facilitate the guardianship process and to help with filing of forms and conversations with the hospital legal department. At this point, the case manager asked for an ethics consult before “we strip this guy of all his rights and force him to go to a place he does not want to be.”

10. Good Help to Those in Need. ® BON SECOURS VIRGINIA HEALTH SYSTEM Topics Of Concern Patient Autonomy The Right to make Bad Decisions Guardianship and patient rights

11. Good Help to Those in Need. ® BON SECOURS VIRGINIA HEALTH SYSTEM Patient Autonomy In contemporary American ethics, “autonomy” is understood as individual autonomy. Each person determines for themselves the goods that they will pursue in life. Effectively, each of us determines for ourselves what a good life will look like.

12. Good Help to Those in Need. ® BON SECOURS VIRGINIA HEALTH SYSTEM Bad Decisions What makes a decision bad? A decision is bad when the actions it leads to turn us away from some value, valuable activity, or valuable state. Mr. V’s decisions are medically bad because they systematically lead him away from health and physical wellness.

13. Good Help to Those in Need. ® BON SECOURS VIRGINIA HEALTH SYSTEM Bad Decisions Evaluations of actions always presuppose sets of values. In any decision there are multiple sets of values being used to evaluate the choices as good, bad, better, or worse.

14. Good Help to Those in Need. ® BON SECOURS VIRGINIA HEALTH SYSTEM The Right to Make Bad Decisions Patient Autonomy upholds the patient’s right to request or refuse medical care based on the patient’s values. Those values cannot be ignored simply because they do not align with the values of medical providers or the medical community. A bad medical decision can nevertheless be a good decision for a patient.

15. Good Help to Those in Need. ® BON SECOURS VIRGINIA HEALTH SYSTEM Bad Decisions Decisions may be bad due to many reasons. The first two would be “bad” bad decisions. 1.Lack of knowledge. We might make a mistake or not know a relevant fact. 2.Lack of reasoning. We might not take account of new information or situations. 3.Lack of consensus around values. We might simply disagree about whether a choice upholds a worthwhile value.

16. Good Help to Those in Need. ® BON SECOURS VIRGINIA HEALTH SYSTEM The Right to Make Bad Decisions A good bad decision results from: 1.Knowledge of the situation and the relevant information. 2.Consistent reasoning about new information and situational changes. 3.Flows from the values of the person(s) making the decision.

17. Good Help to Those in Need. ® BON SECOURS VIRGINIA HEALTH SYSTEM Guardianship The law recognizes the distinction between good bad decisions and bad bad decisions. A person receives a guardian when they are making “bad” bad decisions. That is, when they can no longer reason about new information, new situations, or their own values. A capacity evaluation is designed to determine whether the patient is making “bad” bad decisions.

18. Good Help to Those in Need. ® BON SECOURS VIRGINIA HEALTH SYSTEM Mr. V’s Bad Medical Decisions What kind of bad medical decisions is Mr. V making? Follow-up psych evaluations by psychiatry and psychology revealed that Mr. V is: 1. Able to take in and retain new information 2. Able to make reasoned decisions according to his own values 3. Unable to integrate new information into his reasoning processes.

19. Good Help to Those in Need. ® BON SECOURS VIRGINIA HEALTH SYSTEM Ethical Analysis Mr. V is making “bad” bad decisions. The recommendation from Ethics was to pursue guardianship and continue with in-patient psychiatric therapy. In this case, we are not taking a patient’s rights to make bad decisions away. We are acknowledging the reality of the patient’s condition and working to ensure his safety and continued physical and mental health.

20. Good Help to Those in Need. ® BON SECOURS VIRGINIA HEALTH SYSTEM Conclusion of the Case Mr. V has spent over 100 days in the hospital awaiting a court appointed guardian and showed some progress with consistent psychiatric therapy. While he is still not capable of making decisions for himself, he is showing some signs of improved reasoning.

21. Good Help to Those in Need. ® BON SECOURS VIRGINIA HEALTH SYSTEM Questions?

22. Good Help to Those in Need. ® BON SECOURS VIRGINIA HEALTH SYSTEM Thank you! Nicholas Setliff, PhDc Bon Secours Virginia Health System Nicholas_Setliff@bshsi.org