My favorite cog screen is Six Item Screener
3-item recall and temporal orientation (day of week, month, year)
Must score 5 or 6
Acad Emerg Med;2005;12:612
Med Care 2002;40:771
Abbreviated Mental Test
The Abbreviated Mental Test can be used to quickly test the cognitive function in elderly patients. This is also referred to as the Hodkinson’s Mental Test Score.
time to the nearest hour
name of place where pt currently is
recognition of 2 persons
birthday (date and month)
date of World War I
name of President
able to count from 20 to 1 backwards
address – 42 West Street (given at beginning)
minimum score: 0
maximum score: 10
A higher score indicates greater cognitive function.
A score of 6 is used as the cutoff to separate normal elderly persons from those who are confused or demented with a correct assignment of 81.5%.
Short Blessed Test
administer the short blessed test from this worksheet
Pt should paraphrase risks and benefits
THE CRITICAL PATIENT WHO REFUSES TREATMENT: AN ETHICAL DILEMMA Palmer, R.B., et al, J Emerg Med 15(5):729, 1997 The authors, from the Universities of New Mexico and Arizona, discuss ethical considerations that may arise when emergency physicians must make treatment decisions for critically ill patients. In these circumstances, physicians must utilize a “best-interest” criterion when formulating management plans for patients who are unable to provide informed consent. Informed consent requires that a patient possess decision-making capabilities, receive and comprehend all information about the risks and benefits of a proposed intervention, and willingly consent to treatment. In the ED, the ability of patients to make these decisions may be impaired by the direct effects or the anxiety and stress produced by an illness or injury, as well as by medications administered. In these circumstances, implied consent covers lifesaving procedures that a “reasonable” person would wish to be performed. Emergency physicians must be capable of determining a patient’s ability to make treatment decisions, but must avoid manipulation of the patient to consent to an intervention. Physician “paternalism” operates to transfer decision-making from the patient to the physician in accordance with what the physician determines to be in the best interests of the patient. There should be no conflict between the legal and ethical considerations of treatment decisions made by physicians for patients who are unable to provide consent. Emergency physicians must evaluate the ability of critically ill patients to make treatment decisions in the context of the potentially serious consequences of the treatment options and the best-interest standards of care. THE CHILD JEHOVAH’S WITNESS PATIENT: A LEGAL AND ETHICAL DILEMMA Groudine, S.B., Surgery 121(3):357, March 1997 The author, from the Albany Medical Center in New York, reviews legal and ethical issues relating to blood transfusions in minor Jehovah’s Witness patients. In the current legal environment, it is difficult to override an adult patient’s right to self-determination. Thus, physicians caring for adult Jehovah’s Witnesses must be prepared for refusal of transfusions by these individuals. If the physician has difficulty with this position, he or she may contact the Hospital Information Services of the Jehovah’s Witnesses in Brooklyn, NY (718-625-3600) for referral to other physicians or facilities experienced in dealing with these patients. The author advocates discussion with the adult Jehovah’s Witness who requires blood transfusions to determine if they will accept individual blood components, and use of blood conservation techniques when possible. In the case of children, courts have upheld the concept that adults do not have the right to expose their children to ill health or death and have supported administration of life-saving transfusions to minors against parental wishes. Guardians should be consulted when minors cannot offer legal consent. Dissenting parents should not be forced to sign a transfusion consent form as this approach may be associated with social and religious stigma and loss of dignity. The author advocates the use of an acknowledgement form that recognizes the parents’ beliefs while indicating that child welfare authorities will be notified, or emergency transfusions will be given as permitted and required by the courts, if a situation occurs in which transfusion is necessary. The author advises physicians and facilities to develop policies and procedures in advance to avoid confusion when the situation occurs, and indicates that transfusion of children against parental wishes should be an uncommon necessity with proper advance planning and use of blood-conserving technologies. HOW MUCH DO DOCTORS KNOW ABOUT CONSENT AND CAPACITY? Jackson, E et al, J Roy Soc Med 95:601, December 2002 BACKGROUND: There is increasing attention to individual patient’s rights and participation in medical decision making. These issues require accurate assessment of the patient’s capacity to consent which may fluctuate with time and the complexity of the matter at hand. In today’s litigious society, the accuracy of a physician’s judgment regarding a patient’s capacity to consent may be subject to legal scrutiny. METHODS: The authors of this British study surveyed 190 physicians (psychiatrists, general practitioners [GPs and geriatricians) and medical students to determine their knowledge base concerning assessment of seven areas of patients capacity for decision making. These included consent to (or refusal of) medical treatment, consent to research, testamentary capacity (making a will), driving, managing financial affairs sexual relationships and voting. The items included in the questionnaire were based on guidelines published by British legal and medical societies. RESULTS: Analyzable responses were received from 68% of those surveyed. Only 31% of respondents were correct in their knowledge regarding capacity to consent to or refuse medical treatment (58% of psychiatrists, 34% of geriatricians, 20% of GPs and 15% of medical students). Fifteen percent of respondents incorrectly believed that, under common law they may forcibly treat a competent adult who is refusing treatment. Only 7% responded correctly on the issue of testamentary capacity. CONCLUSIONS: These results highlight the need for education of physicians regarding the issue of assessing patient capacity. THE MYTH OF INFORMED CONSENT: IN DAILY PRACTICE AND IN CLINICAL TRIALS Silverman, W.A., J Med Eth 15(1):6, March 1989 The author, from the College of Physicians and Surgeons of Columbia University, discusses issues relating to informed consent. Prior to 1957, the physician’s duty to provide medical benefits (often consisting of provision of hope and comfort) typically surpassed the obligation to respect patient autonomy. However, this concept changed in 1957 with the Salgo decision, in which it was concluded that physicians have a duty to disclose facts that are necessary for the patient to make an informed decision. The standard of informed consent elaborated in that legal decision called for provision of information concerning the nature, consequences, potential harm and benefits, and risks and alternatives to patients, thereby permitting them to have adequate information concerning potential choices. The author cites an apparent lack of meaningful implementation of informed consent in daily practice. In a 1982 survey, it was noted that while most physicians obtained written consent (80%) or written and oral consent (15%) prior to surgery or anesthesia, the majority (93%) appeared to be unaware that this process was intended to permit patients to make a choice or state preferences concerning treatment. The author cites the following previously proposed criteria for informed consent in daily practic e: “the patient must agree to an intervention based on an understanding of (usually disclosed) relevant information; consent must not be controlled by influences that would engineer the outcome; the consent must involve the intentional giving of permission for an intervention.” The substantial differences between consent in daily practice and in clinical research studies are cited. THROMBOLYSIS FOR ACUTE ISCHEMIC STROKE: THE PROBLEM OF CONSENT Ciccone, A., et al, Neurol Sci 22:339, 2001 Although thrombolytic therapy for acute ischemic stroke has been approved in the United States and Canada, consensus on the risk-benefit profile of this treatment is lacking and it is not authorized in most European countries. This Italian report comments on the issue of consent for thrombolytic therapy for stroke. Consent for any treatment may be difficult in the ED setting due to the hectic environment, time constraints, and the acute nature of the illness. In one study, 20% of ED patients were incapable of fully understanding information provided. This is compounded for the stroke patient due to the very nature of the illness. In the NINDS trial, which provided the basis for FDA approval of thrombolytic therapy for stroke, IV tPA given within three hours after symptom onset was associated with a higher rate of return to a completely autonomous life after three months (50 vs. 39% of untreated controls), but an increased likelihood (6 of possibly fatal cerebral hemorrhage during the first few days Consideration of this risk-benefit profile requires complex evaluation skills and application of personal value judgments Obtaining consent from family members has been criticized, because family members may be unaware of patient preferences or may feel uncertainties about making such choices. Although physicians are often authorized to make treatment choices in life-threatening situations, it must be acknowledged that thrombolytic therapy may be considered to be “disability-saving” but not necessarily “life-saving.” The authors’ proposal for the Italian model may be applicable to practice in North America. They suggest formulation of a departmental protocol citing specific circumstances in which this treatment might be applied, with multidisciplinary input and participation by the hospital ethics committee. EVIDENCE-BASED MEDICINE AND INFORMED CONSENT Kapp, M.B., Acad Med 77(12):1199, December 2002 Current emphasis on evidence-based medicine (EBM) represents an attempt to assist physicians in applying a scientific context to custom, habit, their own experience and traditional teaching. The author, an attorney who teaches at Wright State University School of Medicine, comments on EBM in the context of a physician’s obligation to inform patients fully about proposed medical interventions (noting that about half of the states in the U.S. have adopted patient-oriented legal standards of informed consent In the past, patients generally assumed that recommended treatments were based on “some intellectually defensible evidentiary basis,” but this may not always have been the case. Knowledge that a physician’s recommendations are based on sources other than evidence from clinical research could complicate the informed consent process for the patient The author feels that it is uncertain if such full disclosure (“in the absence of scientific evidence, you’ll just have to trust me”) would frighten patients rather than empower them in the decision-making process Similarly, he wonders whether patients would be more likely to reject proposed treatments for which there is no scientific proof of benefit, and if such rejection on this basis would best serve the ethical principles of patient autonomy. The author concludes that the role of the patient in the movement towards EBM and informed consent should not be overlooked. IMPRACTICABILITY OF INFORMED CONSENT IN THE REGISTRY OF THE CANADIAN STROKE NETWORK Tu, J.V., et al, N Engl J Med 350(14):1414, April 1, 2004 BACKGROUND: The development of registries of patients with different clinical conditions is an important method of monitoring trends in patient care. Concerns about privacy have prompted legislation mandating that informed consent be obtained before a patient is included in such registries in some countries. METHODS: This multiinstitutional Canadian study evaluated a comprehensive consent process employed for inclusion of patients in a national registry for stroke and transient ischemic attack. The registry involved 20 hospitals in eight provinces. Consent pamphlets were provided to patients and their surrogates, and dedicated nurses were instructed in methods of obtaining consent for participation in the registry as well as other registry tasks including data abstraction. RESULTS: In the first phase (June 2001 through February 2002), consent for inclusion in the registry was obtained for only 39.3% of 4,285 eligible patients. After modifications to streamline the process, consent for inclusion was obtained for 50.6% of 2,823 eligible patients in the second phase (June-December 2002). Reported barriers to obtaining consent included death or discharge of the patient before enrollment, absence of the patient from his/her room when the nurse coordinator attempted to conduct the interview, and the demands of an overwhelming workload. Clinical and demographic differences were identified between patients who did and did not provide consent for participation. CONCLUSIONS: These findings suggest that the generalizability of patient registry information appears to be limited by suboptimal patient participation and issues of selection bias. ASSESSMENT OF PATIENT CAPACITY TO CONSENT TO TREATMENT Etchells, E., et al, J Gen Intern Med 14(1):27, January 1999 METHODS: The authors, from the University of Toronto, examined agreement between the general impression of the treating staff physician, evaluation using a semi-structured Aid to Capacity Evaluation (ACE) instrument administered by a resident or senior student and by a research nurse, Standardized Mini-Mental Status Examination (SMMSE) scores, and formal capacity assessment by two experts among 100 inpatients (median age, 74) facing nonemergency treatment decisions. The study included only those patients who had refused treatment, or who had accepted treatment but were not judged to be clearly capable of consenting. The ACE instrument explored seven relevant issues, and included discussion of the treatment in question. RESULTS: When compared with the consensus expert opinion, the areas under the receiver-operating characteristic curves were 0.86 for the general impression of the managing clinician, 0.90 for use of the ACE instrument by a resident or senior student, 0.93 for administration of the SMMSE by a research nurse, and 0.95 for use of the ACE instrument by a research nurse. The likelihood of incapacity was significantly increased when an ACE result consistent with definite or probable incapacity was combined with a SSMSE score of 0-16 (likelihood ratio [LR] 40.0), and significantly decreased when an ACE result of definite or probable capacity was combined with a SSMSE score of 24-30 (LR 0.05). CONCLUSIONS: The authors suggest that use of specific instruments to assess a patient’s capacity to consent to treatment may increase the reliability of the assessment. The ACE instrument is available at www.utoronto.jcb/. THE CASE FOR “PRESUMED CONSENT” IN ORGAN DONATION Kennedy, I., et al, Lancet 351(9116):1650, May 30, 1998 The authors of this multinational paper discuss the concept of “contracting out” (the equivalent of presuming consent) with regard to organ donation. In countries with a “contracting in” policy, in which donors or their relatives must actively indicate their willingness for organ removal for transplantation, the supply of organs has not kept pace with demand. In several countries (Spain, Austria and Belgium) with a “contracting out” policy, in which organs may be removed after death unless the individual has specifically indicated unwillingness to participate, the supply of organs has increased since implementation of this policy. The authors feel that most persons who are willing to donate organs do not provide formal declaration of their intentions during their lifetime, thus limiting (and possibly preventing) use of organs after death. They cite key provisions of the “contracting out” laws in Belgium, where citizens wishing to opt out of the donation program may register their objections at any Town Hall, and a computerized registry facilitates identification of these objections. Furthermore, patients’ physicians may decide against removal of organs from a patient if they believe this action would cause undue distress. The authors believe that a “contracting out” policy would increase organ supply while at the same time reducing the emotional burden on grieving relatives. They believe that, in developed countries, effective systems can be set in place to ensure that the wishes of persons not willing to participate can be respected. While acknowledging that changes in a country’s organ donation policy must be preceded by informed public debate, they argue that the time has come to initiate such discussion. MUST CONSENT ALWAYS BE OBTAINED FOR A DO-NOT-RESUSCITATE ORDER? Layson, R.T., et al, Arch Intern Med 156(22):2617, December 9/23, 1996 In current practice, cardiopulmonary resuscitation (CPR) is initiated for nearly all patients sustaining a cardiac or respiratory arrest unless otherwise specified, usually in the form of a “do-not-resuscitate” (DNR) order which is generally believed to require consent by the patient or surrogate. The authors, from the University of North Carolina, discuss the dilemma that physicians may face when confronted with a clearly terminal patient who refuses to consent to a DNR order. Transfer of the patient’s care to another physician may not always be feasible and discussion of the medical realities of the situation may not necessarily persuade the patient to acknowledge the futility of CPR. A case is discussed in which a patient with terminal HIV infection refused to consent to a DNR order in the face of imminent death. The treating physician wrote the order without informing the patient. The authors contend that this physician acted in an ethically proper manner. They point out that the commonly accepted definition of autonomy may preempt the freedom and choices of others, forcing a physician to act against his or her own conscience. The authors further note that initiation of futile CPR represents a misallocation of medical resources, and jeopardizes healthcare workers by unnecessarily exposing them to physical and psychological harm. They point out that failure of the physician to advise the patient of the DNR order was not prompted by maleficence, but was rather an attempt by the physician to allow the patient to maintain his coping mechanism. The authors acknowledge the potential abuse of power that may occur if physicians are permitted to write unilateral DNR orders. They suggest the formulation of policies regarding the management of patients for whom limitation of treatment is considered, and encouraging ethics consultations for physicians who are contemplating unilateral DNR orders. —–Original Message—– From: Antonios Liolios [mailto:firstname.lastname@example.org] Sent: Wednesday, March 29, 2006 11:45 AM To: Lex, Joseph; email@example.com Subject: RE: ccml thats all i get? Physician’s attitude and practice regardingpatient’s rightsduring medical emergencies Sorry for the vagueness. I mean if anyone has encountered a study (or a questionnaire in the context of a study) regarding how physicians deal with patients’ rights during emergencies. Do you overcome consent in view of a life threatening situation? When and how do you do that? Etc etc I hope this makes it clearer otherwise I will resend the question in Greek Antonios —–Original Message—– From: Lex, Joseph [mailto:Joseph.Lex@tuhs.temple.edu] Sent: Wednesday, March 29, 2006 5:37 PM To: Antonios Liolios; firstname.lastname@example.org Subject: RE: ccml thats all i get? Physician’s attitude and practice regardingpatient’s rightsduring medical emergencies What exactly are you looking for? I don’t understand the “questionnaire” request. Give me an example of what questions you want answered. If I understand what you are looking for appropriately, I don’t believe I’ve seen anything on this topic in the peer reviewed literature. However there are frequent discussions in the monthly “throwaways” Emergency Medicine News and Emergency Physician Monthly. Joe Lex, MD, FAAEM Past Chair, Education Committee American Academy of Emergency Medicine
Box: Test of capacity
There are three stages to the decision
- To take in and retain the information
- To believe it
- To weigh that information, balancing risks and needs
Given time and proper explanations many patients will consentto treatment. If, despite this, a patient who has been determinedas having capacity still refuses treatment, then his or herdecision should be respected. This situation will rarely occurwhen there is a serious risk to the patients health.The level of capacity required has to match the seriousnessof the decision to be made.16 Therefore, patients may have thecapacity to refuse treatment for a minor laceration, but notto refuse life-saving treatment for a potentially lethal overdose.In such situations it will normally be possible to show thatthe patient did not have the ability to weigh up the informationto arrive at a valid decision.17 It would certainly be advisableto seek legal advice before allowing a patient to refuse life-savingtreatment.
You must document:
Diagnosis and Recommended Treatment with Risks and Benefits
Alternatives to Care
Document the presence of family or friends involved in the decision
Adequate follow-up care
for AMA, must document MMSE IMAJO-mental status judgment pt can paraphrase
Decision-making capacity is defined by four criteria: (i) ability to communicate a choice, (ii) ability to understand the relevant information, (iii) ability to appreciate the situation and its consequences, and (iv) ability to reason about treatment options.(8) Appelbaum PS. Assessment of patients’ competence to consent to treatment. N Engl J Med. 2007;357:1834-1840.
Case Reports and HIPAA Physicians must assure that the case report does not contain any of the 18 health information identifiers noted in the HIPAA regulations, unless authorization from the individual (s) has been obtained. The authorization is not required if neither of the 18 identifiers below are used in the case report. List of 18 Identifiers: 1. Names; 2. All geographical subdivisions smaller than a State, including street address, city, county, precinct, zip code, and their equivalent geocodes, except for the initial three digits of a zip code, if according to the current publicly available data from the Bureau of the Census: (1) The geographic unit formed by combining all zip codes with the same three initial digits contains more than 20,000 people; and (2) The initial three digits of a zip code for all such geographic units containing 20,000 or fewer people is changed to 000. 3. All elements of dates (except year) for dates directly related to an individual, including birth date, admission date, discharge date, date of death; and all ages over 89 and all elements of dates (including year) indicative of such age, except that such ages and elements may be aggregated into a single category of age 90 or older; 4. Phone numbers; 5. Fax numbers; 6. Electronic mail addresses; 7. Social Security numbers; 8. Medical record numbers; 9. Health plan beneficiary numbers; 10. Account numbers; 11. Certificate/license numbers; 12. Vehicle identifiers and serial numbers, including license plate numbers; 13. Device identifiers and serial numbers; 14. Web Universal Resource Locators (URLs); 15. Internet Protocol (IP) address numbers; 16. Biometric identifiers, including finger and voice prints; 17. Full face photographic images and any comparable images; and 18. Any other unique identifying number, characteristic, or code (note this does not mean the unique code assigned by the investigator to code the data)
Pay for Performance
These measures are currently flawed, of course anyone in medicine who actually practices could tell you that