Introduction The following principles are intended to be applied only to a variety of individual situations you may face on the USMLE Capacity, Competence, and Consent Capacity vs competence capacity is a medical term competence is a legal term Assessing capacity ability to receive and process the information ability to express a choice ability to understand the potential consequences of the decision ability to rationalize their choice Competent patients have the right to refuse medical information and medical treatment(s) a feeding tube is a medical treatment a competent person can refuse lifesaving hydration or nutrition Assume that the patient is competent unless history of suicide attempt psychotic patient cannot communicate Obtain informed consent patient must understand risks benefits alternatives including no treatment patient must agree with plan of care without coercion exceptions emergencies waiver by patient patient lacks decision-making capacity therapeutic privilege physician deprives an unconscious or confused patient of his autonomy in order to protect the patient's health (paternalism) note that written consent can be revoked orally at any time components of informed consent include: patient makes and communicates a choice patient is informed information has not been withheld from the patient decision remains stable over time decision is consistent with patient's values and goals decision is not result of delusions or hallucinations temporally incapacitated patients, depending on mental state, may provide informed consent consent from a patient's spouse is not required treatment of a patient with capacity End-of-Life Issues If the patient cannot make decisions, surrogate decision makers must use the following criteria: subjective standard (advance directive of patient) living will = patient provides specific instructions to withhold or withdraw life-sustaining treatment substituted judgment (what would the patient want) durable power of attorney = patient designates healthcare proxy to make decisions supersedes living will if both exist "best interests" of the patient when no living will or durable power of attorney exists, the clinician is responsible for determining an appropriate surrogate decision maker from available family members the priority of next-of-kin for surrogate decision making is as follows: legal guardian appointed by a court spouse adult children (> 18 yrs) parents adult siblings grandparents/grandchildren friend of the patient Euthanasia passively allowing patient to die is acceptable but do everything you can to relieve patient's suffering active killing of the patient is not acceptable When treatment should stop physician thinks treatment is futile but family insists on treatment continue treatment after declaration of brain death but family insists on treatment stop treatment Code status refers to the level of interventions a patient would want should they undergo cardiopulmonary arrest must be determined for any critically-ill patient admitted to the hospital on initial history can include full code (all interventions), do not resuscitate (DNR, or no interventions), or limited code (some interventions) Confidentiality Confidentiality between physician and patient is generally absolute exceptions suspicion of child/elder abuse domestic violence is not an exception physicians should ensure patients have a safe place to go communicable disease must be reported gunshot or stabbing injuries must be reported to the police the patient is a harm to others or self Tarasoff decision held that doctors have a duty to warn of imminent harm to others no alternative means exists to warn others patient waves right to privacy e.g. for insurance purposes Minors Minors cannot give informed consent unless emancipated through: marriage a parent military service living alone A minor's refusal of treatment can be overruled by a parent Parents cannot withhold life- or limb-saving treatment from their children, but can refuse other treatments Examples 17-year-old girl whose parents cannot be contacted physician may treat a threat to health under in locum parentis 17-year-old girl living on her own patient can choose whether or not to give consent 17-year-old girl who is requests birth control provide access even in absence of parental consent 17-year old girl who requests treatment for an STI notification of parents is not required 16-year-old girl refuses but mother consents treat 16-year-old girl consents but mother refuses do not treat Other Principles Avoid going to court Use trained medical interpreters when possible Committed mentally ill patients retain their rights Never abandon a patient transferring a patient to another physician's care is rarely (if ever) a correct answer on the USMLE If a treatment (such as abortion, birth control, etc) is against a physician's personal beliefs - that physician does not have to provide that treatment; however, they are responsible for referring their patient to a provider who is willing and able to provide such care Disclose all errors, regardless of harm consulting risk management alone is rarely (if ever) a correct answer on USMLE Directive counseling should be performed when patients need guidance to make a choice that is clearly superior Child and Elder Abuse If suspected abuse is occurring, physicians are mandated reporters and MUST report