Medical Decision-Making Capacity and Ethical Considerations
Assessment of medical decision-making capacity is challenging and especially complicated for victims of elder abuse. Given the complex nature of this work, this chapter aims to introduce concepts and ethical considerations related to decision-making for vulnerable older adults, to present the current practice for assessing capacity to make medical decisions and to consider research and future directions. Despite the goal to achieve shared decision-making with older adults and provide patient center care, capacity assessment is still needed when one suspects that an older adult cannot understand the situation and the consequences of the medical decisions which the older adult is making when the decisions may cause irreparable harm. Physicians may turn to established guidelines, standardized forms, and ethics committees to effectively utilize medical decision-making capacity assessments. Depression and dementia are common among abused older adults and can impair their abilities to appreciate decisions they are making about their medical care. These capacity assessments may influence legal guardianship or conservatorship proceedings, but are different from legal determinations to appoint a guardian or conservator due to incapacity or incompetence. Once a physician deems an older adult to lack capacity, the physician consults surrogate decision makers in order to provide the appropriate care. If there are no health care proxies assigned, surrogate decision makers are prioritized under state law, which varies from state to state. Despite ethical challenges and other barriers to understanding decision-making capacity in older adults, future developments in technology and patient-centered research may provide the tools needed to improve current practices.
KeywordsCapacity Incapacity Incompetence Guardianship Conservatorship Shared decision-making
- 1.Agency for Healthcare Research and Quality. Making Health Care Safer II; Rockville, MD; 2013. Retrieved from http://www.ahrq.gov/research/findings/evidence-based-reports/ptsafetyuptp.html. March 7, 2016.
- 2.American Bar Association. Guardianship Law and Practice. Retrieved from http://www.americanbar.org/groups/law_aging/resources/guardianship_law_practice.html. March 7, 2016.
- 3.American Bar Association. Health Care Decision Making. Retrieved from http://www.americanbar.org/groups/law_aging/resources/health_care_decision_making.html. March 7, 2016.
- 4.American Medical Association. Ethics Opinion 8.08, Informed Consent; 2006. http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion808.page?. March 7, 2016.
- 5.American Psychological Association. ABA/APA assessment of capacity in older adults. Retrieved from http://www.apa.org/pi/aging/programs/assessment/. March 7, 2016.
- 7.Appelbaum PS, Grisso T. MacCAT-CR:MacArthur competence assessment tool for clinical research. Sarasota, FL: Professional Resource Press; 2001.Google Scholar
- 11.Brandl B, Dyer CB, Heisler CJ, Otto JM, Stiegel LA, Thomas RW. Elder abuse detection and intervention: a collaborative approach. New York, NY: Springer; 2007.Google Scholar
- 12.Caulfield SE. Health care facility ethics committees: new issues in the age of transparency. Am Bar Assoc Sect Civ Rights Soc Just. 2007;34(4). http://www.americanbar.org/publications/human_rights_magazine_home/human_rights_vol34_2007/fall2007/hr_fall07_caulfi.html. March 7, 2016.
- 13.Centers for Elders and the Court. Guardianship Basics. Retrieved from http://www.eldersandcourts.org/Guardianship/Guardianship-Basics/State-Laws.aspx. March 7, 2016.
- 14.Chin JJ. Doctor–patient relationship: from medical paternalism to enhanced autonomy. Singp Med J. 2002;43(3):152–5.Google Scholar
- 17.Edersheim JG, Brendel RW, Price BH. Neuroimaging, diminished capacity and mitigation. In: Simpson JR, editor. Neuroimaging in forensic psychiatry: from the clinic to the courtroom. Wiley; 2012. Google Scholar
- 23.Levin A. Coercion and autonomy sometimes collide in patient-care decisions. Psychiatric News; 2014;49(12). Google Scholar
- 28.Mental Disability Advocacy Center. Legal capacity in Europe: a call to action to governments and to the EU. October 2013. Retrieved from http://mdac.info/en/resources/legal-capacity-europe-call-action-governments-and-eu. March 17, 2016.
- 34.Nilsson A. Who gets to decide? Right to legal capacity for persons with intellectual and psychosocial disabilities. Council of Europe, Commissioner for Human Rights Issue Paper. February 20, 2012.Google Scholar
- 37.Rudrauf D. Structure-function relationships behind the phenomenon of cognitive resilience in neurology: insights for neuroscience and medicine. Adv Neurosci. 2014;1–28.Google Scholar
- 41.Stiegel LA, Wood EF. Nine ways to reduce elder abuse through enactment of the uniform adult guardianship and protective proceedings jurisdiction act. Bifocal, e-journal of the ABA Commission on Law and Aging 2009;30(3):1–6.Google Scholar
- 43.United Nations Convention on the Rights of Persons with Disabilities. Accessed online www.un.org/disabilities/default. March 7, 2016.
- 44.United States. The Belmont Report: ethical principals and guidelines for the protection of human subjects research. Bethesda, MD: The Commission; 1978.Google Scholar