Medical Decision-Making Capability of Patients With Dementia

The United States Census Bureau envisions that by 2010 almost 13% of the United States population will be over the age of sixty-five. The aged are among the most quickly flourishing sections of the US population and are anticipated to account for more than 20% of the gross population by 2050.1 In 2001, the preponderance of dementia in North America was 6.4%. A 49% growth in the amount of folks with dementia is predicted by 2020, and a 172% increase by 2040. Patients with dementia might lack the capability to consent to treatment. The need to appraise capability to consent to treatment will consequently increase as the maturating population grows.

Case Sketch

Mrs E, who is 80 years old, resides in the community with the assistance of a 24-hour-a-day home health aide. She's forgetful and necessitates aid with numerous activities of day-to-day living.

Mrs E is brought in for evaluation since she's been crying more often. She stays in bed for most of the day, doesn't engage in activities she used to relish, and is sleeping and eating to a lesser degree usual. The physician recommends a test of an antidepressant drug, which Mrs E turns down. She says, “I’m eighty years old and I am not about to begin taking medications now. That would kill me!”

How can her physician ascertain whether she has the mental ability to reject treatment for depression?

In 1990, Congress authorized the Patient Self-Determination Act (PSDA). The PSDA compels many Medicare and Medicaid suppliers—including hospitals, nursing homes, hospices, and HMOs—to give patients info about their rights, including their right to take or reject medical or surgical treatment. The law distinctly specifies that occupants of nursing homes keep their right to accept or decline treatment. Our society sets a great value on a persons self-reliance by broadly granting folks to arrive at conclusions for themselves, even if the determinations bestow the peril of significant damage (e.g., bungee jumping).

Several of the rights that we take for granted come from the judicial construct of a “liberty interest” that protects persons from uninvited encroachments on their person. Many people wonder whether an individual with dementia should keep this sense of self and liberty or whether family members should reach medical determinations for him or her. During the previous ten years, there's been an enhanced acknowledgement that individuals with dementia retain a sensation of self, complete with preferences, in spite of cognitive deprivation.

There are a lot of precautions in place to protect an individuals independence. Particularly, the philosophy of informed consent for medical treatment has been contrived to maintain a patient’s self-reliance by constraining the physician from touching, operat-ing on, medicating, or exercising control without the patient’s conveyed accord. This philosophy holds to all individuals, including patients with dementia.

How Much Info is Too Much?

Informed consent in a medical circumstance consists of three elements: revealing of info, willful acceptance of treatment, and mental capability. In this report, we talk about whether patients with dementia can provide informed consent for treatment and how doctors can manage such consent.

Let us first of all analyse the chief component of informed consent: information. How much and what sort of info should the doctor share? Does it assist the patient to acknowledge that 1 in a thousand patients undergo an especially severe untoward effect? What if 1 in a hundred patients has an insignificant response: would that alter whether the patient should be told about the possible harmful event?

2 landmark court cases have cleared up how much info should be rendered. Firstly, the court in Natanson v Kline demonstrated that the clinician should offer info that the “logical medical practician” would customarily expose to a patient. Afterward, in Canterbury v Spence, a court changed its posture and found that the physician should provide data that a “rational individual” would wish to know in order to choose whether to take or reject the projected treatment. This change from what the reasonable practician would talk about to what the reasonable individual would wish to know guided the clinician to regard knowledge of the patient’s particular considerations and psychological state.

It's acceptable for doctors to use therapeutic prerogative and withhold certain info at their circumspection whenever they deem that the info would present an earnest psychological threat by cognitively overpowering the patient or inducing panic.




“Under the care of Leo J. Borrell, M.D. since December 2001, I have seen a remarkable improvement in my mother’s condition. She is responding dramatically to the new regiment Dr. Borrell has prescribed”

- Beth Rose


Feb 3, 2008

The Interdisciplinary Team; The Role of the Psychiatrist

by Dr. Leo J. Borrell, featured in Assisted Living Consult for November/December 2006. A HealthCom Media Publication