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COMPETENCY ISSUES AND DEMENTIA
PMDA’s 16th Annual Symposium
October 24, 2008
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Presenters
Kenneth Brubaker, MD, CMD
Geriatric Program Director
Lancaster General Hospital
Lancaster, PA [email protected]
Paula G. Sanders, Esquire
Post & Schell PC17 North 2nd Street,
12th FloorHarrisburg, PA [email protected]
om
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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
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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.
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Many Types of Capacity
1) Driving2) Living3) Financial4) Medical5) Testamentary
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Physician Competency Judgments (%) Normal Controls [n=16]
0
10
20
30
40
50
60
70
80
90
100
MD 1 -Geripsy
MD 2 -Neurologist
MD 3 -Neurologist
MD 4 -Geriatrician
MD 5 -Geriatrician
Marson et al. 1997 JAGS
CompetentIncompetent
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Physician Competency Judgments (%) Mild AD Patients [n=29]
0
10
20
30
40
50
60
70
80
90
100
MD 1 -Geripsy
MD 2 -Neurologist
MD 3 -Neurologist
MD 4 -Geriatrician
MD 5 -Geriatrician
Marson et al. 1997 JAGS
Competent
Incompetent
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Capacity to Consent to Medical Treatment
Autonomy vs. Protection/Safety
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Conceptual Model Based on U.S. Case Law
a. Ability to Understandb. Ability to Appreciatec. Ability to Reasond. Ability to Make a Choice
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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
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What Options are Available for Treatment?
1) Keep comfortable2) Vascular evaluation3) Bilateral amputations
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Ability to Understand
Comprehend meaning of the information
Repeat in your own words the facts.
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Ability to Appreciate
Recognize the facts apply to you Tell me in your own words what
your medical problem is.
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Ability to Choose
Repeat in your own words what options are available.
What is your choice and can consistently hold to the same choice.
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Ability to Reason
How will your choice affect you? Why have you eliminated the other
choices?
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Dealing with Conflict between POA, Resident, and Care-Giver
a) Educationb) Conflict Resolution (Ethics
Committee)
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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.
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Tests Used for DMC
1) Capacity to Consent to Treatment Instrument (CCTI)
Marson, et al, 1995 3 categories – capable, marginally capable,
incapable2) Assessment of Capacity for Everyday Decision
Making (ACED) www.pennadc.org3) Masonic Village tool
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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.
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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.
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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.
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Act 169: Option for DefaultHealth 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.
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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)
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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
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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
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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
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Dispute Resolution Among Health Care Representatives
Medical treatment according to acceptable standards of practice must be started or maintained until a dispute is resolved.
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Documentation Issues
What to write When to write How often to write
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REFERENCES
Marson et al., Cognitive models that predict physician judgments of capacity to consent to mild Alzheimer’s disease. JAGS 45, 458-464, 1997
Appelbaum,P.S.,Grisso,T. (1988) Assessing patients' capacities to consent to treatment. New England Journal of Medicine, 319,1635-1638.
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, 949-954.
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, 3-11.
PA Act 169: www.pahealthcaredecisions.wetpaint.com/page/ACT+169%3A+Table+of+Parts+%26+Sections