Psych · Old age psychiatry — capacity, guardianship and end of life
Capacity, guardianship and end-of-life decisions
Also known as Decision-making capacity in older adults · Guardianship and substitute decision-making · Advance care planning psychiatry · End-of-life capacity assessment · Appelbaum capacity geriatric psychiatry · Palliative psychiatry end of life · Surrogate decision-making older adults
Exam-exhaustive fellowship reference on capacity, guardianship and end-of-life decisions in older adults — Appelbaum–Grisso four abilities, dementia and delirium capacity gradients, guardianship and surrogate frameworks without invented statutes, advance care planning and directives, goals-of-care discussions, and palliative psychiatric issues including depression and desire for hastened death. FRANZCP-primary, globally tagged.
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Red flags
- Global label of incapacity from age or dementia diagnosis alone without naming the decision and failed abilities
- Emergency medical risk with incapacity — do not delay necessary treatment solely for elaborate testing; document necessity principles under local law
- Using Mental Health Act detention as a default nursing-home placement tool when capacity/guardianship pathways are the correct frame
- Family conflict overriding known values or a valid advance directive without legal review
- Request for hastened death with untreated severe depression, delirium, or uncontrolled pain — assess and treat reversible drivers urgently
- Discharging an incapable older person to an unsafe home or to an unauthorised decision-maker
Meet the patient
An 86-year-old woman with moderate Alzheimer disease is admitted with aspiration pneumonia. She is bright enough between naps to tell you, clearly and repeatedly, that she wants to go home.[4][7]
Her son holds an enduring power of attorney. He wants a feeding tube and full resuscitation. A community nursing entry from two years ago records her saying she never wanted tubes, and that she had watched her husband die that way.[8][16]
Three questions are now live. Can she decide about the tube? If not, who may — and on what authority? And by what standard must that person choose? Almost every old-age capacity viva is those three questions wearing different clothes.[1][14][16]
References20ShowHide
- [1]Appelbaum PS, Grisso T Assessing patients' capacities to consent to treatment N Engl J Med, 1988.PMID 3200278
- [2]Appelbaum PS Clinical practice. Assessment of patients' competence to consent to treatment N Engl J Med, 2007.PMID 17978292
- [3]Grisso T, Appelbaum PS, Hill-Fotouhi C The MacCAT-T: a clinical tool to assess patients' capacities to make treatment decisions Psychiatr Serv, 1997.PMID 9355168
- [4]Raymont V, Bingley W, Buchanan A, et al. Prevalence of mental incapacity in medical inpatients and associated risk factors: cross-sectional study Lancet, 2004.PMID 15488217
- [5]Sessums LL, Zembrzuska H, Jackson JL Does this patient have medical decision-making capacity? JAMA, 2011.PMID 21791691
- [6]Kim SY, Karlawish JH, Caine ED Current state of research on decision-making competence of cognitively impaired elderly persons Am J Geriatr Psychiatry, 2002.PMID 11925276
- [7]Karlawish JH, Casarett DJ, James BD, et al. The ability of persons with Alzheimer disease (AD) to make a decision about taking an AD treatment Neurology, 2005.PMID 15883310
- [8]Silveira MJ, Kim SY, Langa KM Advance directives and outcomes of surrogate decision making before death N Engl J Med, 2010.PMID 20357283
- [9]Sudore RL, Fried TR Redefining the "planning" in advance care planning: preparing for end-of-life decision making Ann Intern Med, 2010.PMID 20713793
- [10]Wright AA, Zhang B, Ray A, et al. Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment JAMA, 2008.PMID 18840840
- [11]Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer N Engl J Med, 2010.PMID 20818875
- [12]Block SD Assessing and managing depression in the terminally ill patient Ann Intern Med, 2000.PMID 10651602
- [13]Breitbart W, Rosenfeld B, Pessin H, et al. Depression, hopelessness, and desire for hastened death in terminally ill patients with cancer JAMA, 2000.PMID 11147988
- [14]Shalowitz DI, Garrett-Mayer E, Wendler D The accuracy of surrogate decision makers: a systematic review Arch Intern Med, 2006.PMID 16534034
- [15]Wendler D, Rid A Systematic review: the effect on surrogates of making treatment decisions for others Ann Intern Med, 2011.PMID 21357911
- [16]DeMartino ES, Dudzinski DM, Doyle CK, et al. Who decides when a patient can't? Statutes on alternate decision makers N Engl J Med, 2017.PMID 28402767
- [17]Okai D, Owen G, McGuire H, et al. Mental capacity in psychiatric patients: Systematic review Br J Psychiatry, 2007.PMID 17906238
- [18]Hindmarch T, Hotopf M, Owen GS Depression and decision-making capacity for treatment or research: a systematic review BMC Med Ethics, 2013.PMID 24330745
- [19]Ganzini L, Goy ER, Dobscha SK Prevalence of depression and anxiety in patients requesting physicians' aid in dying BMJ, 2008.PMID 18842645
- [20]Buchanan A Mental capacity, legal competence and consent to treatment J R Soc Med, 2004.PMID 15340019