Fluctuating Decision-Making in People with Mental Illness

View Large Image Figure ViewerDownload Hi-res image Download (PPT) Robert was an older man who lived independently and worked full time. He diagnosed simultaneously with metastatic cancer myasthenia gravis, autoimmune neuromuscular disorder that causes muscle weakness in the eyes, face, throat. Due to his cancer, only treatment available high-dose steroids. While strength improved, he later hospitalized steroid-induced psychosis. discharged assisted living community where fluctuated between days of psychosis – demanding leave periods lucidity marked by sincere remorse understanding care needs. did not have advance directives guide decision making. Caring for residents fluctuating decision-making capacity due underlying mental illness is a difficult ethical dilemma. At its core delicate balance preserving resident autonomy, right self-determination, principle beneficence, or obligation protect from harm. This dilemma common bound grow as post-acute long-term population continues high acuity complex To help PALTC providers address this meet needs illness, we will provide framework assessment capacity. First, let’s clarify distinction two commonly confused concepts: competency. Capacity medical determination made provider specific at There are four generally accepted criteria evaluate capacity:•The ability understand relevant information.•The state decision.•The explain how information applies.•The reason compare consequences. Context important. A physician requires higher threshold if stakes high, such patients likely die they hospital during massive heart attack, than low, patient diabetes wants scoop ice cream. Competency legal judge typically global evaluation. If court finds person lacks manage her affairs, been found incompetent. Declaring someone incompetent strips individuals many their rights, so done through intensive proceedings. The usually name guardian given responsibility care, comfort, maintenance person. Guardianship comes types. Limited guardianship gives authority make decisions spelled out letter guardianship. Full full, blanket authority. In either situation, guardians must allow participate exercise rights much allowed comprehension. absence guardianship, each has hierarchy decision-making. our North Carolina, example, making falls (in order) power attorney, spouse, majority reasonably parents adult children, siblings, individual established relationship patient, attending confirmation second physician. final concept difference consent assent. Consent voluntary agreement after discussion anticipated risks potential benefits. ability, previously discussed. Assent willingness without give consent. For severe cognitive impairment may why taking antibiotic pneumonia thus cannot consent, but can assent agreeing swallow pill. Returning Robert’s case, community. role clinician first determine whether moment, relatively bar needed harm leaving would pose. does capacity, it leave. not, surrogate maker should be identified. impact steroids on mentation consequences leaving. Because court-appointed use identify wife maker. After situation explained, she decides stay facility. staff working able safely behavior. redirected favorite snacks, wandering garden, distracted another topic conversation. benefits medication management — including decreasing adding antipsychotics well repeat hospitalization limits facility discussed spouse team. It important note facilities, particularly communities are, few exceptions, authorized physical restraints administer medications. imminent danger himself staff, contact emergency services transfer level (such department hospital) initiate 72-hour hold, which allows administration psychotropic medications involuntarily. justified because lack real risk serious injury death leaves, inability Fluctuating challenging By following outline presented here, hope provided general approach balancing principles involved medicolegal considerations play. Dr. Omid Salaami advanced clinical fellow geriatric medicine Duke University. Katja Elbert-Avila director associate professor