Incompetent Patients Research Articles

Respiratory support withdrawal in intensive care units: families, physicians and nurses views on two hypothetical clinical scenarios

IntroductionEvidence suggests that dying patients' physical and emotional suffering is inadequately treated in intensive care units. Although there are recommendations regarding decisions to forgo life-sustaining therapy, deciding on withdrawal of life support is difficult, and it is also difficult to decide who should participate in this decision.MethodsWe distributed a self-administered questionnaire in 13 adult intensive care units (ICUs) assessing the attitudes of physicians and nurses regarding end-of-life decisions. Family members from a medical-surgical ICU in a tertiary cancer hospital were also invited to participate. Questions were related to two hypothetical clinical scenarios, one with a competent patient and the other with an incompetent patient, asking whether the ventilator treatment should be withdrawn and about who should make this decision.ResultsPhysicians (155) and nurses (204) of 12 ICUs agreed to take part in this study, along with 300 family members. The vast majority of families (78.6%), physicians (74.8%) and nurses (75%) want to discuss end-of-life decisions with competent patients. Most of the physicians and nurses desire family involvement in end-of-life decisions. Physicians are more likely to propose withdrawal of the ventilator with competent patients than with incompetent patients (74.8% × 60.7%, P = 0.028). When the patient was incompetent, physicians (34.8%) were significantly less prone than nurses (23.0%) and families (14.7%) to propose decisions regarding withdrawal of the ventilator support (P < 0.001).ConclusionsPhysicians, nurses and families recommended limiting life-support therapy with terminally ill patients and favored family participation. In decisions concerning an incompetent patient, physicians were more likely to maintain the therapy.

Admission of incompetent patients to intensive care: Doctors' responsiveness to family wishes

Admission of incompetent patients to intensive care: Doctors' responsiveness to family wishes

Admission of incompetent patients to intensive care: Doctors' responsiveness to family wishes

Admission of incompetent patients to intensive care: Doctors' responsiveness to family wishes

COUNTERFACTUAL REASONING IN SURROGATE DECISION MAKING - ANOTHER LOOK

Incompetent patients need to have someone else make decisions on their behalf. According to the Substituted Judgment Standard the surrogate decision maker ought to make the decision that the patient would have made, had he or she been competent. Objections have been raised against this traditional construal of the standard on the grounds that it involves flawed counterfactual reasoning, and amendments have been suggested within the framework of possible worlds semantics. The paper shows that while this approach may circumvent the alleged problem, the way it has so far been elaborated reflects insufficient understanding of the moral underpinnings of the idea of substituted judgment. Proper recognition of these moral underpinnings has potentially far-reaching implications for our normative assumptions about accuracy and objectivity in surrogate decision making.

Discussing prognosis with terminally ill cancer patients and relatives: A survey of physicians’ intentions in seven countries

Objective To determine the extent to which physicians in different countries intend to inform terminal patients and relatives about prognosis, and to identify physician characteristics associated with an active approach to such discussions. Methods In the context of a European research project, a study on disclosing prognosis was conducted in seven countries. A written questionnaire with questions regarding hypothetical cases and actual practices was sent to physicians from specialties involved in the care of dying patients. Results 10,139 questionnaires were studied. The response rate was greater than 50% in all countries except Italy (39%). The percentage of physicians who indicated that they would actively inform competent patients of their prognosis varied between countries from 52% in Italy to 99% in Sweden. For informing relatives of incompetent patients, rates were higher, ranging from 86% in Denmark to 98% in Australia. Younger physician age and training in palliative care were associated with an active intention to discuss prognosis. Conclusion Physicians’ intentions to discuss prognosis with patients and families vary largely across countries. Physician age and training in palliative care may also affect intentions. Practice implications Continuing training should focus on improving physicians’ ability to communicate responsibly about prognosis with patients and families.

PO34-FR-03 Attitude of Filipino neurologists in the end-of-life care (EOLC) in acute severely stroked incompetent patient

PO34-FR-03 Attitude of Filipino neurologists in the end-of-life care (EOLC) in acute severely stroked incompetent patient

Advance directives in dementia: issues of validity and effectiveness

Although advance directives may seem useful instruments in decision-making regarding incompetent patients, their validity in cases of dementia has been a much debated subject and little is known about their effectiveness in practice. This paper assesses the contribution of advance directives to decision-making in the care of people with dementia, with a special focus on non-treatment directives and directives for euthanasia. The relevant problems from the ethical debate on advance directives in cases of dementia are summarized and we discuss how these relate to what is known from empirical research on the validity and effectiveness of advance directives in the clinical practice of dementia care. The ethical debate focuses essentially on how to respond to the current wishes of a patient with dementia if these contradict the patient's wishes contained in an advance directive. The (very limited) empirical data show that the main factors in medical decision-making in such cases is not the patient's perspective but the medical judgment of the physician and the influence of relatives. Insight into the experiences and wishes of people with dementia regarding advance directives is totally lacking in empirical research. Ethics and actual practice are two "different worlds" when it comes to approaching advance directives in cases of dementia. It is clear, however, that the use of advance directives in practice remains problematic, above all in cases of advance euthanasia directives, but to a lesser extent also when non-treatment directives are involved. Although generally considered valid, their effectiveness seems marginal. Further empirical research into the (potential) value of advance directives in dementia care is recommended.

Die Patientenverfügung als Kommunikations- und Entscheidungsinstrument

The concept of 'living will', also known as 'advanced directive', emerged in response to modern medical technologies and aggressive medical treatments being implemented in ambiguous situations such as a poor prognostic state. A living will aims at protecting the patient's right to autonomy in such a situation. Ideally, it is a substitute for the actual informed consent or refusal in situations where the individual is unable to express his or her will due to incapacity. At least, a living will can usefully inform medical-ethical decision-making on behalf of an incompetent patient. A living will can either be very general or very specific. It may hold specific directives about the use or foregoing of potentially burdensome medical treatments including food and water to be supplied by feeding tubes or other medical devices. In addition of being a helpful tool for respecting a patient's autonomy, a living will may be regarded as an opportunity for improving communication about death and dying with patients and healthy people alike.

ESPEN Guidelines on Parenteral Nutrition: Geriatrics

Older subjects are at increased risk of partial or complete loss of independence due to acute and/or chronic disease and often of concomitant protein caloric malnutrition. Nutritional care and support should be an indispensable part of their management. Enteral nutrition is always the first choice for nutrition support. However, when patients cannot meet their nutritional requirements adequately via the enteral route, parenteral nutrition (PN) is indicated. PN is a safe and effective therapeutic procedure and age per se is not a reason to exclude patients from this treatment. The use of PN should always be balanced against a realistic chance of improvement in the general condition of the patient. Lower glucose tolerance, electrolyte and micronutrient deficiencies and lower fluid tolerance should be assumed in older patients treated by PN. Parenteral nutrition can be administered either via peripheral or central veins. Subcutaneous administration is also a possible solution for basic hydration of moderately dehydrated subjects. In the terminal, demented or dying patient the use of PN or hydration should only be given in accordance with other palliative treatments.

ML02P ADULT SURGICAL PATIENTS: THE QUESTION OF COMPETENCY TO CONSENT

Surgeons are well aware of the legal and ethical implications of failing to provide informed consent. However, consenting patients for surgical procedures becomes more challenging when there is a question regarding the patient's competency, especially when the patient is refusing life saving treatment.In Australia, the Common Law presumes every adult is competent to consent to medical treatment until proven otherwise. There are three capacities one requires for competency in decision making and hence the ability to consent to treatment. Firstly a person requires the capacity for understanding and communication. Secondly, they need to be able to reason and deliberate and thirdly a person requires a set of values or the conception of good.Guardianship legislation exists in all states involving consent to medical treatment of adults who lack capacity to consent on their own behalf. This legislation exists to protect the autonomy of the patient and promote their best interests. It provides for a substitute decision maker to act on behalf of the incompetent patient.I will refer to a number of factors which may interfere with a patient's competency to give consent or refuse treatment, some of which are reversible. I will discuss the definition of competency of adults to consent or refuse treatment with reference to current laws in Australia, the issue of autonomy and the duty of care a surgeon must provide their patient in regards to informed consent in the context of the incompetent patient.

Law and Language: How Words Mislead Us

This talk was the Reappointment Lecture for the Frederick W. Thomas Chair in the Interdisciplinary Study of Law and Language at the University of Minnesota. The topic is the way that the words we use in legal doctrinal reasoning can - intentionally and unintentionally - mislead us regarding the proper outcomes of cases and the best development of the law. Connecting to the ideas of the American legal realists Oliver Wendell Holmes, Jr., and Felix Cohen, the talk uses examples from Contract Law (assent to terms in electronic contracting cases, waiver of the failure of conditions), Medical Decision-Making (deciding on behalf of incompetent patients), and Family Law (same-sex marriage, child custody, and alimony) to make general points about how we choose words to make our decisions more persuasive or more comfortable, when we should instead be using more transparent (more honest) terminology, in order better to confront the real underlying moral and policy questions.

The Right to Refuse Life-Sustaining Medical Treatment in South Korea: The Case of Ms. Kim*

In North America and elsewhere there exists a legal and ethical consensus concerning the right of patients to refuse life-sustaining treatment and the right of families or other proxies to make such decisions for patients who are themselves unable to do so. This consensus emerged gradually and through several landmark legal rulings, such as those made in the cases of Karen Ann Quinlan and Nancy Cruzan. In South Korea, on the other hand, there is no consensus on the rights of families to make decisions concerning the refusal of life-sustaining treatment on behalf of incompetent patients and, until recently, there was no legal recognition of a patient’s right to refuse life-sustaining treatment. However, the situation in Korea seems to be changing with the recent court rulings in the case of Ms. Kim, a case which may do for medical practice in Korea what the case of Karen Ann Quinlan did for the practice of medicine in the US. This paper makes a contribution to the much-needed consensus-building process in Korea by reviewing some of the landmarks cases in the international right-to-die movement, identifying the key legal and ethical lessons from those cases, and then applying those lessons to the case of Ms. Kim in order to evaluate the decisions that have been made in her case so far and to make further recommendations on what else needs to be done.

Admission of incompetent patients to intensive care: Doctors’ responsiveness to family wishes*

When a patient is incompetent, the family is often considered to be a natural surrogate. The doctors' responsiveness to family wishes may vary. We explored if doctors' personal characteristics were associated with responsiveness to the relatives' wishes when admission to the intensive care unit (ICU) is considered. In a mail survey, we asked all Swiss ICU doctors to decide on the admission of a hypothetical incompetent patient presenting with hemolytic uremic syndrome. Each participant was randomly allocated to a version of the scenario in which the family asked either that "everything be done" or that the patient be "spared useless suffering." Overall, 232 (60.9%) questionnaires were returned. When the family asked that "everything be done," 60% of doctors chose to admit the hypothetical patient, but when the family asked that she be spared useless suffering, only 39% did so (odds ratio [OR] 2.6, confidence interval 1.5-4.6). This OR captures responsiveness to family wishes. It varied across subgroups of ICU doctors. Characteristics associated with greater responsiveness to family wishes were older age (OR 6.0 vs. 1.2, p = 0.002), nonuniversity work setting (OR 4.2 vs. 1.0, p = 0.012), less time devoted to intensive care practice (OR 4.0 vs. 1.5, p = 0.036), and greater self-confidence in ethical knowledge (OR 3.4 vs. 1.7, p = 0.044). Older doctors and those working in regional hospitals were more responsive to family wishes when assessing an incompetent patient for ICU admission. These findings emphasize the need for effective advance care planning.

S30-02 Geriatric psychiatry and human rights in Romania - involuntary treatment

The protection of human rights and the dignity of persons with mental disorders has not a relatively short history in Romania. We have a short review of legislation and of conditions of hospitalization concerning involuntary commitment of the mentally ill people during our history before and after 1989, having more than 30 years experience in the field. Since 1989 it has been necessary to create committees to investigate abuse during involuntary commitment. On the other hand, before 1989 some persons with (or even without) mental disorders were committed to a psychiatry department to protect them. Generally, Romania's legislation is in keeping with principles set out by the World Health Organisation, United Nations and so on, concerning the protection of people with mental illnesses. The legislation calls for adequate treatment and respect for the human rights of the persons with mental disorders.Standards and practice regarding involuntary commitment in a psychiatric department and also involuntary ambulatory treatment of person with mental disorders have been improved since the introduction of the new mental health law in 2002. We discuss about the assessment of competence in the elderly and ethical aspect of care and research, and about involuntary commitment of incompetent elderly patients. We also refer to the complications and difficulties when trying to apply the civil commitments compulsive hospital admission measure. Involuntary commitment of incompetent patients took in the consideration the best interest of the patient, but also the well-being of the family and the potential risk for others.

End-of-Life Care in Israel—The Dying Patient Law, 2005

After years of political stalemate on the issue of end-of life medical care in Israel, the Knesset enacted the Dying Patient Law in 2005. This Article argues that the new law manifests a paradigm shift in the normative framework regulating end-of-life treatment in Israel, from a patient right approach based on the principle of autonomy, to a physician duty approach based on the principle of the sanctity of life. In so doing the law created a complex web of formal procedural rules and culturally unique legal artifices, which amount to a maze of medicolegal technocracy. The technocratic maze conceals substantive restrictions on rights to patient autonomy which had been recognized in the former case law in relation to the withholding and withdrawal of medical treatment. In particular, under the new law, the request of a competent patient to withdraw artificial respiration may not be respected, and the advance directives of an incompetent patient to withhold artificial nutrition are of no effect. Beyond a question of constitutionality, the Article suggests that the underlying approach of the law to death and dying is an unskillful response to the challenges that have arisen from life extending technology.

S70-01 Forensic psychiatry in the elderly-ethical issues

We discuss about psychiatric and psychological expertise exams and about the assessment of competence in the elderly and ethical aspect of care and research in elderly demented or not demented people and about involuntary commitment of incompetent patients.We also refer to the complications and difficulties when trying to apply the civil commitments compulsive hospital admission measure, foreseen in the law for mental health, when the dementia diagnostic falls within this age group. Historically, involuntary commitment of incompetent patients took in the consideration the best interest of the patient, but also the well-being of the family and the potential risk for others.After a short review of legislation and of conditions of hospitalization concerning involuntary commitment of the mentally ill people during our history before and after 1989, we'll analyze the activity on involuntary commitment in a Forensic Psychiatry Hospital in district Bihor, in last five years from a 30 years experience working in the field. Standards and practice in our country regarding the involuntary commitment have been changed more that three times after the second War and has been improved in 2002, when there appeared the new Mental Health Law, emphasizing protection of patients’ rights. There are legal and ethical limits to involuntary hospitalisation, because involuntary treatment and hospitalisation restricts a person's liberty. There should be a lot of things to do to improve the quality standards: improvement of elementary care needs, improvement of their quality of life.

Surrogate decision makers for incompetent ICU patients: a European perspective

Frequently, ICU patients lack the capacity to share discussions and make decisions about their health. Designation of a surrogate and advance directives have been proposed to empower patients and give more place to their autonomy. Even though legitimacy of surrogates is now recognized by physicians, patients' management must take into account new legislations emphasizing patients' autonomy all over Europe. Over the last decade, most western European countries have recognized the validity of advance directives and the process of substitute decision making when a patient is incapacitated. Although the laws of these countries reflect the same approach, there are several differences in the mode of designation of surrogates and in their decisional authority. The present review compares the legal framework of surrogacy in Belgium, Denmark, England, France, Germany, the Netherlands, Spain, and Switzerland. France is the country that confers the weakest power to surrogates in decision making. Patients' competence and the ability of surrogate decision makers to cope with ICU's burden are discussed as the main limitations of the substitute decision-making process. Measures to improve substitute decision making and to limit harmful repercussions are suggested.

La centralità della volontà del paziente incapace in una recente sentenza della Corte di Cassazione

A recent judgement by the Court of Cassation about a request – by the legal guardian of an incompetent patient in permanent vegetative state – of suspension of artificial nutrition and hydration, gives important instructions about informed consent, right of self-determination, and right to refuse treatment in competent and incompetent patients, with particular regard to the role of legal guardian and to the validity of advance care directives.

Ethische Erwägungen in der klinischen Forschung mit psychisch Kranken

The review deals with present problems of protecting mentally ill patients who are incompetent to give informed consent to participating in clinical research, and of assessment of the capacity to consent. 1. Clinical trials of drugs on efficacy and safety in incompetent patients are ethically justified and legally admissible if the investigational drug can be expected to exert a direct potential individual benefit and if such trials will be performed under defined criteria to protect these vulnerable patients. In Germany it is questionable how far these prescriptions of the German Drug Law (AMG) are transferable to other than drug research. 2. Research with no direct potential individual benefit or only a group-specific benefit in incompetent patients is controversially discussed. However, it may be ethically justified as an exception, and is in Germany legally admissible only in minors, but not in adults. 3. However, internationally there exists a wide range of legal regulations, terms, interpretations, and practices of research with vulnerable persons. In the past years a shift seems to have developed from normatively oriented discussions to more empirically based investigations. Especially vague but clinically relevant terms in protection declarations or guidelines have been better specified, put in concrete form by anchor examples, and empirically studied. 4. In general the criteria of protecting the dignity and, even if impaired, the autonomy of incompetent patients as subjects for research appear to guarantee a high standard of protection. However, the application of these criteria must be improved by practicable procedures. This is valid particularly for the assessment of the basic criterion whether a patient is capable of consenting or not. 5. Open Questions are formulated as need of research.

Nobody likes premies: the relative value of patients’ lives

The objective of this study was to examine whether patient selection or triage requires placing a relative value on human lives and whether the values placed on these lives are consistent with current ethical theories. An anonymous questionnaire was administered to groups of physicians and students in Montreal. It presented eight currently incompetent patients with potential neurological sequelae requiring emergency care. Predicted outcomes were explicitly described. Four patients had a predicted 50% survival and a 50% chance of impairment; they were a preterm and a term neonate, a 2-month-old and a 50-year-old. Two already disabled patients, a 7-year-old and an 80-year-old, had 50% predicted survival. A 14-year-old and a 35-year-old had 5% survival, but differing impairment. Respondents were asked if they would resuscitate and in what order they would resuscitate if all needed intervention simultaneously. Eighty-five percent response rate, n=524. The proportion stating they would always resuscitate was smallest for the 80-year-old (18% P<0.001 compared to other patients), then the preterm (35%, P<0.001), then the term and the 50-year-old (53 and 58%, P<0.01). The 2-month-old and the 7-year-old would be resuscitated most frequently (74 and 77%, P<0.01), followed by the patients with 5% survival (64 and 68%, P<0.001). The median order of triage was first the 2-month-old, followed by the 7-year-old, the 14-year-old, the term newborn, the 50-year-old, the 35-year-old, the premature newborn and the 80-year-old. Order of resuscitation was not closely related to the predicted survival, impairment or potential life years gained. Age appeared to have a strong influence, with children's lives being valued more than the adults'. This tendency was reversed for the newborn infants who were undervalued compared with older children, and most particularly for the premature. The value placed on the life of newborns, in particular the premature, is less than that expected by any objective medical data and was not consistent with any ethical theory that we tested.