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Capacity, revisited: A case report of a patient with guardianship who refuses life prolonging treatment
Journal of the Academy of Consultation-Liaison Psychiatry ( IF 2.7 ) Pub Date : 2020-10-01 , DOI: 10.1016/j.psym.2020.10.007
Pooja R Sarkar 1 , Shannon L Mazur 2 , Peter A DePergola 3 , Walter J Kilpatrick 1
Affiliation  

Abstract Introduction Consultation liaison psychiatrists may be asked to evaluate for capacity when a patient with guardianship refuses life-saving treatment. The team and guardian may turn to the Consultation psychiatrist for guidance if they themselves are uncertain of the patient’s true values or underlying wishes. While these consultation requests may be dismissed as unnecessary, we argue there is merit to clarifying the uncertainties that prompted the consultation. Case An elderly man with diabetes, dementia, and court-appointed guardianship, developed progressive sepsis and required bilateral above-the-knee amputations to prolong his life. When he refused these amputations, the surgery team placed a capacity consultation request, as both the team and guardian were unsure if this refusal reflected his underlying values. Methods We examine relevant literature and judicial precedents to explore the role of values-based discussions with patients legally determined to lack competency. We furthermore collaborate with an Ethics consultant to investigate the underlying reason for placing such a consultation request, which in this case stemmed from the clinical team’s hesitancy to perform the amputations. Conclusion While the Consultation liaison team did not ultimately assess for capacity to refuse the amputations, the team drew upon noncognitive factors to glean insight into the patient’s underlying values. This guided the guardian in applying substituted judgement to determine the approach in the best interest of the patient.

中文翻译:

能力再谈:监护人拒绝延长生命治疗的病例报告

摘要 介绍 当有监护权的患者拒绝挽救生命的治疗时,可能会要求咨询联络精神科医生评估其能力。如果团队和监护人自己不确定患者的真实价值观或潜在愿望,他们可能会向咨询精神科医生寻求指导。虽然这些咨询请求可能被认为是不必要的,但我们认为有必要澄清导致咨询的不确定性。案例 一名患有糖尿病、痴呆症和法院指定监护人的老人,发展为进行性败血症,需要双侧膝上截肢以延长其生命。当他拒绝这些截肢手术时,手术团队提出了能力咨询请求,因为团队和监护人都不确定这种拒绝是否反映了他的基本价值观。方法 我们查阅相关文献和司法先例,以探讨与法律认定缺乏能力的患者进行基于价值观的讨论的作用。此外,我们还与道德顾问合作,调查提出此类咨询请求的根本原因,在这种情况下,这源于临床团队对进行截肢手术的犹豫。结论 虽然咨询联络小组最终没有评估拒绝截肢的能力,但该小组利用非认知因素来深入了解患者的基本价值观。这指导监护人应用替代判断来确定最符合患者利益的方法。此外,我们还与道德顾问合作,调查提出此类咨询请求的根本原因,在这种情况下,这源于临床团队对进行截肢手术的犹豫。结论 虽然咨询联络小组最终没有评估拒绝截肢的能力,但该小组利用非认知因素来深入了解患者的基本价值观。这指导监护人应用替代判断来确定最符合患者利益的方法。此外,我们还与道德顾问合作,调查提出此类咨询请求的根本原因,在这种情况下,这源于临床团队对进行截肢手术的犹豫。结论 虽然咨询联络小组最终没有评估拒绝截肢的能力,但该小组利用非认知因素来深入了解患者的基本价值观。这指导监护人应用替代判断来确定最符合患者利益的方法。结论 虽然咨询联络小组最终没有评估拒绝截肢的能力,但该小组利用非认知因素来深入了解患者的基本价值观。这指导监护人应用替代判断来确定最符合患者利益的方法。结论 虽然咨询联络小组最终没有评估拒绝截肢的能力,但该小组利用非认知因素来深入了解患者的基本价值观。这指导监护人应用替代判断来确定最符合患者利益的方法。
更新日期:2020-10-01
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