00:01
So now let's talk about
patients where you've determined
that they lacked
decision making capacity.
00:06
There are going to be
some special considerations
in how we take care of
these kinds of patients.
00:11
And I'm thinking about
three kinds of patients
that might have
decisional impairment.
00:15
The first would be the
patient that had capacity,
but as a result of delirium,
perhaps they have temporarily
lost their capacity to
make their own decisions.
00:26
We talked about that
in previous lecture.
00:29
There may also be patients
that previously had capacity,
but now it's permanently been
lost as a result of cognitive decline.
00:37
So a dementia patient that has lost
the ability to make their own decisions.
00:43
And third, there might be
patients who have lack of decision
making capacity that never
had capacity in the first place.
00:49
And that would be individuals that
have developmental intellectual disability.
00:53
So they're adults, but they don't
have the ability to make their decisions.
00:58
So all of these kinds of
patients that don't have capacity,
once we've made
that determination,
we're going to need to think
about some specific things.
01:07
At the start,
it's important to recognize that
they may still retain the
ability to make some decisions.
01:12
So thinking back to the
sliding scale notion of capacity,
there may be simple
decisions that even patients that
globally might not be able to
make more complex decisions,
they still might be able
to make simple decisions.
01:25
And it might also be possible
with them to ask ascent or descent,
so yes or no to a treatment.
01:31
And that's something we talked
about in the informed consent lecture.
01:35
It's also important to recognize
that maybe there are things
we can do as clinicians to
help people to have capacity.
01:43
So whenever possible, trying to build
up their capacity to make decisions,
whether that's aiding
their understanding
in terms of how we
describe the information,
if we draw pictures,
if we really try to bolster,
their information
processing ability,
or it maybe they have the medical
condition that's created delirium.
02:02
If we remove the conditions for the
delirium, they regain their capacity,
all of these things are
going to be important to
what we ultimately want to do is,
you know,
if possible,
help people make their own decisions.
02:15
When it is not possible when
they are truly incapacitated,
then we need to find another
person to make decisions for them.
02:23
So in the informed
consent lecture,
we talked about the
ability of a surrogate
decision maker to speak
on behalf of the patient.
02:30
And we talked about two
standards by which surrogates
can make decisions for patients
that lacked decision making capacity.
02:37
Either a substituted judgment,
so they know the
patient well enough,
they know the patient's values,
that they can apply it to the
particular medical situation,
to render a decision,
or without really knowing
how the patient would
make the decision.
02:50
They gather all the information,
go through the same
informed consent process
and determine what's in the
best interest of the patient.
02:57
So those are going to be
important things for adults
that lack decision
making capacity.
03:02
So that's for adults,
where we've determined
that they might lack
decision making capacity,
you know, so for minors,
we cannot presume
that they have decision
making capacity.
03:11
But nonetheless,
it's important that we can assess it.
03:14
So especially as we think about
adolescents moving into young adulthood,
they are gaining
increased autonomy.
03:22
And so we want to try to determine
can they make their own decisions.
03:28
And it may be that the
presence or the magnitude
of their capacity to make
decisions is going to vary
with their age and their
cognitive development.
03:36
So a 12-year-old
making a decision
versus a 16-year-old
making decision.
03:40
They may differ,
and it may be jurisdictional as well
as to whether or not we
would permit a younger child
or younger adolescent to
make their own decisions.
03:51
It's also important
for the clinician,
if they're going to be
assessing the capacity of a minor
is making sure that
they are free from any
undue influence by an
authority figure or peer.
04:01
If this really is a means of
demonstrating their own autonomy,
we don't want them to be sort
of influenced by that authority,
that sort of forcing the decision on them,
or peer pressure
that might influence
how they make decisions.
04:14
Similar to what we
would do for adults,
we want to check their capacity
to understand the information,
communicate back
their understanding
of the information
that we've given them,
show that they can reason
about it and deliberate the risks,
the benefits, alternatives,
to make their own decision.
04:31
Now with adolescents,
especially, you know,
it's hard to know if they
have a stable set of values,
you know,
people are growing or developing,
they might change their
value system over time.
04:43
But at least in terms of making
this particular medical decision,
you want to have some
stability in the values
that they're using
to make the decision.
04:52
And lastly, that they have emotional
maturity to make reasoned decisions.
04:56
So again, when we talked about
peer pressure or family pressure,
are they able to withstand
that they have the maturity say,
"Well, no,
I'm making this decision for myself.
05:05
I'm not going to, you know, just
acquiesce to a family member or friend."
Also, you know,
can they handle the fear of having
an illness or being
diagnosed with something?
Can they be emotionally
mature enough to sort of
put the fear aside and come
up with making a decision?
Lastly, you know,
it's also after they've made the decision,
will they have any misgivings
about the decision that they've made?
So a sign of sort of mature decision
maker is they accept the decision,
they try to ollow through
with it and see what happens.