Transcript Forensic Issues at the End of Life

Decision Making at the End of Life
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Pain
Fear
Depression (SI)
Isolation
Cognitive loss
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Ethics
Law
Role of Psychiatrist
Advance Directive
SHC Guidelines
Situations
• Rights of competent patient
• Rights of incompetent patient
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Advance Directive
Surrogate
Guardian
Unrepresented
• Termination of life support
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Vegetative / terminal vs. limited awareness (Schiavo case)
Competent, advance directive, or surrogate
Unrepresented
Guardian
Ethics
• Personal autonomy
– Right to be left alone
– Right to exercise prospective autonomy
• Respect for life
• Substituted judgment
• Best interest
Law
• Landmark Cases
– Right to consent / refuse, right to die
• Health Care Decisions Law (2000)
– Advance Directive
• SHC Guidelines
– Protocols integrated medical custom and the law
Role of the Psychiatrist
• Independent assessment capacity / competency
• Write sufficient good consultation report
• Indicate if / how capacity can be restored
Psychiatric Assessment
• Ability to understand & knowingly / intelligently act upon
consent information using rational processes.
• Determine by questioning patient and doing MSE.
• Are there mental status deficits that cause the impaired
decision?
– Assess level of alertness, information processing, thought
processes , ability to modulate mood and affect.
• Is the impairment substantial? Enduring? Treatable?
Advance Directive
• Exercise of prospective autonomy
– Appoints agent
– Specifies wishes agent is to carry out
• Do you really need one?
– Best interests of another may rule
– If court / guardian involved, see “Wendland.”
• If hospitalized, can easily appoint a surrogate
SHC Guidelines Online
• Adult patient with capacity
• Adult patient lacks capacity but has advance
directive, surrogate, or conservator or person
• Adult patient lacks capacity & has no surrogate
– Medical custom, second opinion, risk management,
(Ethics Committee)
• If decision to withdraw life support, consider exclusions, refer
Ethics Committee, COS, Court (patient Cs rejects)
– See review of law: Conservatorship of Wendland.