00:01
Now, there are also going to
be cases where we have patients
that do not have the ability
to make their own decisions.
00:07
We're going to have another
lecture on assessment
of decision making capacity.
00:11
But in this case, when the patient
can't make their own decisions,
we need to find an
alternatives decision maker
or what we would call a
surrogate decision maker.
00:21
So this is,
in cases where the patient
lacks decision making capacity.
00:26
There's an authority that says
this is the other person
that makes decisions for them
on behalf of them for making
medical treatment decisions.
00:38
So the actual patient may
still be communicative,
they may still be able
to talk to you and so on.
00:45
But they just don't have
the reasoning ability
or the ability to understand all
the information to process it,
to make their own decision.
00:52
We still say they might be able
to accent or descent.
00:56
So accent would mean,
they can express a
willingness to accept the plan
and descend would say, a lack of
willingness to accept the plan.
01:05
So you can think of a child.
01:07
A child does not have
decision making capacity.
01:09
Their parents might need to
make decisions for that child.
01:13
But the child might still
be able to say,
"Yes, I'm willing to take this pill
to make me feel better."
The parent does the informed
consent process on their behalf.
01:23
The child may still be able to say
yes or no to taking the medication.
01:29
And there's another
interesting thing
that been talked about
in medical ethics realms
about use of designated
support persons.
01:37
So is there any opportunities
to bolster the patient
who lacks decision making
capacity in making decisions.
01:45
So they can't make
decisions all by themselves,
but they still might be
able to reach a decision
if they have the
support of a loved one.
01:52
So bringing in a family
member who they trust,
that can sort of guide them through
the decision making process.
01:59
It's still only an ascent or descent
by that patient lacking capacity.
02:03
But that designated
support person who's really
trying to integrate information
they know about the patient
and what the patient is
saying in front of them
to then reach a decision
that's going to work
in the best interest
of the patient.
02:15
So how do we decide on
surrogate decision makers
who's going to be
best able to represent
a patient
in decision making process?
So think for yourselves.
How you would think about
finding a decision
maker for a patient?
I will tell you that it
depends on the jurisdiction.
02:32
So where you practice
medicine or practice nursing,
different jurisdictions might have
a different way of choosing
surrogate decision makers.
02:41
I'm going to give you
a typical ordering,
but you should really check
at your own institution,
where you practice, about how they
decide on surrogate decision makers.
02:53
So a typical ordering
would be
something called
an Advanced Directive.
02:58
The patient while they had
decision making capacity,
while they add the
competence to make decisions,
completed a form that said,
"I named this person to be my proxy,
to be my healthcare agent."
My other term is called durable
power of attorney for health care.
03:15
I want this person to make
medical decisions for me
when I can't make them for myself.
03:21
If that's never been completed,
there might be the need to
go to the court
and have a court
appointed guardian.
03:28
So this is a person that will speak
on behalf of the patient
and make those medical
decisions for them.
03:35
It might be that the guardian has
discretion over lots of decisions
by the incapacitated patient.
Their finances, where they live,
not just their medical care, but for
our purposes, we're thinking about
a court appointed guardian
for medical decisions.
03:52
And then short of those two things,
generally, it's going to be the case
that you're going to rely
on family or friends
to help in making decisions.
04:00
And the typical ordering,
you know, for to go by priority
might be a spouse or
significant other.
04:07
Next, would be an adult child,
then it could be a parent,
adult sibling of the patient,
or any other relative or friend.
04:18
If it's the case
that the surrogates
there multiple people
at the same level,
they all have equal decision making
authority on behalf of the patients.
04:27
So if it's you're thinking
about adult children,
and if there are
more than one child,
and all of them have to agree
on the decisions,
reach consensus amongst themselves,
to make decisions
on behalf of the patient.
04:41
And one of the jobs
of the clinical team
is going to be working
with those loved ones,
to reach a decision that they think
is going to work for the patient.
04:54
And how do surrogates
make decisions?
Well, there are two standards.
04:58
The first would be something
called substituted judgment.
05:01
So they're substituting
themselves and making judgments
based on what they know
of the patient.
05:07
So the patient's own values,
what they know about the
patient's preferences,
what they know about the
patient's ideas about well being,
all of those are factored into
making decisions about the patient.
05:19
These medical decisions that will
impact the patient in their life.
05:24
Maybe that they've had prior
conversations with the patient.
05:27
And now they just have to apply to
this particular medical circumstance
to say, "Well,
this is my substitute judgment
of what the patient would want."
Short of that,
when there isn't the opportunity
to do substituted judgment,
the surrogate decision maker
should rely on best interest.
05:44
So this is
gathering all the information
that's been done in the
informed consent process.
05:49
The surrogate weighs
all that information,
and decides what's going to be best
in the best interest of the patient.
05:55
What would avoid
harm to the patient?
If they can factor in things like,
will it relieve suffering?
Will it preserve function?
Will it help to attend to the
patient's quality of life?
All of those things speak to
the patient's best interest.
06:10
And that's what
the surrogate rely on
when they really
don't know for sure
how the patient would have made
the decision for themselves.