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HLT POL 100 Chapter Notes - Chapter N/A: Gangrene, Internal Medicine, Costs In English Law

Health Policy and Management
Course Code
Marcy Boroff

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HLT POL Week 5 reading 1
A 75-year-old woman with type 2 diabetes mellitus and peripheral vascular disease is admitted with a
gangrenous ulcer of the plantar aspect of her left foot. A surgical consultation results in a
recommendation for a below-the-knee amputation, but the patient declines the procedure on the
grounds that she has lived long enough and wants to die with her body intact. Her internist, who has
known her for 15 years, is concerned that she has been increasingly confused over the past year and now
appears to be depressed. How should her physician determine whether her decision is a competent one?
When patients lack the competence to make a decision about treatment, substitute decision makers
must be sought. Hence, the determination of whether patients are competent is critical in striking a
proper balance between respecting the autonomy of patients who are capable of making informed
decisions and protecting those with cognitive impairment.
Thus, in most situations there is good reason to continue the traditional practice of having physicians
determine patients’ capacity and decide when to seek substituted consent.2 Indeed, statutes regarding
advance directives for medical treatment generally recognize a medical determination of incapacity as
the trigger for activating these directives.3 In addition, since consent obtained from an incompetent
patient is invalid, physicians who do not obtain a substituted decision may be subject to claims of having
treated the person without informed consent.1
Between 3 and 25% of requests for psychiatric consultation in hospital settings involve questions about
patients’ competence to make treatment-related decisions.4,5 In many other cases, impaired decision
making in hospitalized patients may go undetected
One study of 302 medical inpatients with acute conditions estimated that as many as 48% were
incompetent to consent to medical treatment. This group included patients with a broad array of
medical conditions, but most commonly neurologic and infectious diseases.
However, since a range of severity is associated with most diagnoses, no diagnosis in which
consciousness is retained is invariably predictive of incapacity. Data on the diagnostic and other clinical
predictors of incapacity are derived from studies of decisions regarding both consent to receive
treatment and consent to participate in clinical research
Patients with Alzheimer’s disease and other dementias have high rates of incompetence with regard to
such decisions; more than half of patients with mild-to-moderate dementia may have impairment, and
incompetence is universal among patients with more severe dementia
Among psychiatric disorders, schizophrenia has a stronger association with impaired capacity than
depression; roughly 50% of patients hospitalized with an acute episode of schizophrenia have
impairment with regard to at least one element of competence, as compared with 20 to 25% of patients
admitted with depression.1
Among psychiatric patients, lack of insight (the lack of awareness of illness and the need for treatment)
has been reported to be the strongest predictor of incapacity.18
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