Chapter 7: Healthcare Decision-Making
8. Which of the following are core ethical principles that give rise to clinical obligations? Select all that apply. a. Allocating clinical resources to patients who are likely to obtain greatest benefit from them. b. Promoting the patient's best interest and well-being and protecting the patient from harm. c. Supporting and facilitating the capable patient's exercise of self-determination regarding healthcare. d. Avoiding actions likely to cause harm to the patient.
ANS: B, C, D The core ethical principles include respect for autonomy, which means supporting and facilitating the capable patient's exercise of self-determination regarding healthcare, beneficence, which means promoting the patient's best interest and well-being and protecting the patient from harm, and nonmaleficence, which means avoiding actions likely to cause harm to the patient. Allocating clinical resources to patients likely to obtain greatest benefit from them is not a core ethical principle.
5. Which of the following questions are useful in assessing the degree to which the patient has the skills necessary to make an informed healthcare decision? Select all that apply. a. "What do you think you will gain by refusing this surgical intervention?" b. "Why is this decision so difficult for you?" c. "Tell me what the physician explained to you regarding the treatment option." d. "What do you think your daughter would want you to do?"
ANS: A, B, C In order to assess the degree to which the patient has the skills necessary to make an informed healthcare decision, it is imperative to assess the patient's understanding relative to that particular decision. The probes and questions asked must be very specific, keeping in mind the medical intervention that is required. The questions "What do you think you will gain by refusing this surgical intervention?" "Why is this decision so difficult for you?" and "Tell me what the physician explained to you regarding the treatment option" all relate directly to the patient's understanding of the intervention. A question like "What do you think your daughter would want you to do?" is inappropriate, as it is not specific for any particular intervention.
7. Which of the following are important steps in obtaining an informed consent? Select all that apply. a. Disclosure of sufficient material information relevant to the decision in question b. Emphasis on distinctions about efficacy of treatment c. Understanding the information provided d. Consent or refusal to the proposed intervention
ANS: A, C, D Informed consent requires disclosure of sufficient information to the patient (or to surrogates on behalf of patients without decisional capacity), understanding of the information provided, voluntary choosing among the options, and consent or refusal to the proposed intervention. Emphasis on distinctions about efficacy of treatment, whether it would be curative or palliative, can influence a patient's decision. This is referred to as "framing" and must be avoided during the process of obtaining an informed consent.
4. Which of the following statements describing the relationship between risk attached to a decision and capacity required to make a decision are true? Select all that apply. a. The greater the risk attached to a decision, the higher is the level of capacity required to make a decision that will be honored. b. The greater the risk attached to a decision, the lower is the level of capacity required to make a decision that will be honored. c. The lower the risk attached to a decision, the higher is the level of capacity required to make a decision that will be honored. d. The lower the risk attached to a decision, the lower is the level of capacity required to make a decision that will be honored.
ANS: A, D Accurate and useful capacity assessment depends on the recognition that capacity is decision specific and works on a sliding scale based on the notion of risk. The greater the risk attached to a decision, the higher is the level of capacity required to make a decision and will be honored. Similarly, the lower the risk attached to a decision, the lower is the level of capacity required to make a decision and will be honored.
6. A 90-year-old male patient with advanced dementia is admitted to the hospital, as he has stopped eating. On examination, the patient is found to respond to painful stimuli but does not interact, nor does he appear to recognize his family members. A decision regarding placement of a percutaneous endoscopic gastrostomy tube to provide him nutrition has to be taken. His family members do not support this decision because they feel he would never want to be dependent on artificial nutrition and hydration. This kind of decision-making on behalf of the patient due to a lack of capacity to decide medical care for himself is referred to as: a. advanced directive. b. substituted judgment. c. best interest standard. d. instruction directive.
ANS: B In this case, the patient is not capable of making decisions regarding his health. In the absence of any advanced directive, decisions are made by his family members based on the fact that they are close to the patient, so they are aware of and can infer the patient's wishes based on his characteristic behavior and decision-making. This is known as substituted judgment. Advanced directive is of two types: an instruction directive (a list of interventions the patient does or does not want in specified circumstances) or an appointment directive (a health proxy or durable power of attorney for healthcare is identified with the same decision-making authority as the patient.) In a case, where the patient's wishes are not known and cannot be inferred, best interest standard is applied. This is a decision based on what others judge to be in the best interest of an individual who never had or made known healthcare wishes and whose preferences cannot be inferred. Instruction directive, also known as a living will, is a list of interventions the patient does or does not want in specified circumstances.
3. A 65-year-old diabetic patient is brought to the emergency department of a hospital with severe hypoglycemia after taking an overdose of insulin. A detailed history reveals that he lives alone, and often forgets to take his diabetes medication. On a Mini Mental Status Examination he scored 17 out of 30. Which tool should be used to assess the decisional capacity of this patient? a. Assessment of Capacity for Everyday Decision Making (ACED) b. Short Portable Assessment of Capacity for Everyday Decision Making (SPACED) c. Confusion Assessment Method (CAM) d. St. Louis University Mental Status (SLUMS)
ANS: B The patient is a diabetic who lives alone and often forgets to take his medication. The Mini Mental Status Examination score of 17 is well under the cut-off score of 24 and indicates that the patient has a possible cognitive impairment. The Short Portable Assessment of Capacity for Everyday Decision Making (SPACED) can be used to assess the decisional capacity of this patient. This instrument helps to assess the capacity to solve functional problems of older adults with mild to moderate cognitive impairment. SPACED is a shorter version of Assessment of Capacity for Everyday Decision Making (ACED) and allows the examiner to interview a patient with a functional problem that has at least one possible solution (like in this case, the patient forgets to take his medication and home care can provide a weekly pill box). Assessment of Capacity for Everyday Decision Making (ACED) is an instrument used to assess the capacity to solve functional problems of older adults with mild to moderate cognitive impairment. In this case, ACED can be used. However SPACED is a better tool as the patient has a specific functional problem of forgetting to take his diabetes medication. Confusion Assessment Method (CAM) is used to assess for Delirium. It is not required in this case as the patient shows no symptoms of confusion and Mini Mental Status Examination has already been done to assess cognitive functioning. St. Louis University Mental Status (SLUMS) is a screening and staging tool used for assessment of dementia, and is not required in this case.
9. Which of the following are components of Advanced Care Planning (ACP)? Select all that apply. a. Best interest standard b. Instruction directive c. Substituted judgment d. Appointment directive
ANS: B, D Advanced Care Planning (ACP) is a process to enable individuals with decisional capacity to prospectively articulate their health goals, values, and treatment preferences so that they can be communicated and honored when the ability to make and communicate decisions is lapsed. Instruction directives and appointment directives are important components of Advanced Care Planning. An instruction directive includes a list of interventions the patient does or does not want in specified circumstances. An appointment directive is the legal designation of a healthcare agent with the same decision-making authority as the patient. In case of absent explicit instructions from the patient, either verbally or in an advanced directive, decisions by others are based on either substituted judgment or best interest standard. Best interest standard is a decision based on what others judge to be in the best interest of an individual who never had or made known healthcare wishes and whose preferences cannot be inferred. Substituted judgment is a decision by others based on the formerly capable person's wishes that are known or can be inferred from prior behaviors or decisions.
2. A 79-year-old male patient reports to the hospital's emergency department disoriented, yelling, and rambling. He is brought to the hospital by his wife, who found him lying on the floor, unable to answer any questions, and confused. In this condition, the patient is not capable of making decisions about his treatment. How should treatment decisions be made for this patient? a. The required treatments to sustain the patient's life are pursued in spite of the risks, burdens, and benefits. b. Social services are contacted, and someone not related to the patient is appointed as the patient's guardian to make rational decisions on the patient's behalf. c. The patient's wife must make decisions for the patient based on what is determined to be in the patient's best interests. d. The matter must be referred to the hospital's ethics committee.
ANS: C Capacity is a clinical determination that a person has the ability to understand, make, and take responsibility for the consequences of healthcare decisions. When patients are not capable of making decisions regarding their treatment, the authority to act on their behalf is vested in others, like family members or surrogates. In this case, the patient's wife must make decisions for the patient based on what is determined to be in the patient's best interest. The required treatments are continued only after an informed consent is obtained from the patient's family or surrogate. In this case, the patient is accompanied by his wife, so social services need not be contacted for the purpose of making decisions on the patient's behalf. The matter need not be referred to the hospital's ethics committee.
1. Beneficence is one of the core ethical principles underlying the healthcare decision process. It is defined as: a. supporting and facilitating the capable patient's exercise of self-determination regarding healthcare. b. avoiding actions likely to cause harm to the patient. c. promoting the patient's best interest and well-being and protecting the patient from harm. d. allocating fairly the benefits and burdens related to healthcare delivery.
ANS: C The core ethical principles underlying the healthcare decision process and giving rise to clinical obligations include beneficence, respect for autonomy, nonmaleficence, and justice. Beneficence is defined as promoting the patient's best interest and well-being and protecting the patient from harm. Respect for autonomy is supporting and facilitating the capable patient's exercise of self-determination regarding healthcare. Nonmaleficence is avoiding actions likely to cause harm to the patient. Justice means allocating fairly the benefits and burdens related to healthcare delivery and ensuring that decisions are based on clinical need, rather than ethically irrelevant characteristics.
10. A 74-year-old female patient needs to undergo an emergency surgical procedure to relieve intestinal obstruction. When the procedure is explained to the patient to obtain an informed consent, she replies, "Talk to my daughter. She makes all my decisions about important things. Just do whatever she thinks is right." The patient is alert and capable of making decisions for herself. What should be the clinician's next step? a. Refer the matter to the hospital's ethics committee. b. Explain to the patient that she has to make decisions pertaining to her own health. c. Respect the patient's preference and talk to her daughter about obtaining an informed consent. d. Proceed with the best interest standard.
ANS: C The decision of the patient to delegate her daughter to be the decision-maker is an autonomous decision, thus it must be respected. The patient's daughter should be involved and asked to make an informed decision regarding the surgical procedure required for the patient. Since the patient has delegated a trusted person to be the decision-maker, the matter need not be referred to the ethics committee. Best interest standard (decision based on what others judge to be in the best interest of an individual who never had or made known healthcare wishes and whose preferences cannot be inferred) is not required in this case, as the patient has delegated her daughter to make decisions on her behalf. The patient need not be further coaxed to change her decision.
