“The silver tsunami, the demographic imperative — call it what you will. Because of our aging population, we are encountering the question of capacity more and more,” said Erica Wood of the American Bar Association’s Commission on Law and Aging, in her presentation at Jewish Home’s 12th Annual Palliative Care Conference: Meaningful Choice, Patient Capacity and the Practice of Palliative Care held on Wednesday, November 12 at the UJA-Federation headquarters in New York.
More than 150 physicians, nurses, social workers and geriatric administrators gathered at the conference for an exploration of the many facets of geriatric patient decision-making and how a patient’s ability – or capacity – to make decisions impacts treatment choices and palliative care.
With estimates that half of the population over 85 suffers from dementia, the ability of elderly patients to continue to make their own decisions is a complex issue. Wood pointed out that the capacity for decision-making can be fluid. Not only is capacity task specific, but it can change over time; Alzheimer’s could worsen, or an elder could regain capacity that was temporary impaired, as is the case with hospital induced delirium.
The Right to Make Foolish Choices
Patients have the right to participate in their care, whether we agree with their choices or not,” Daniel Maher of Rush University said during his presentation on the practical process of assessing a patient’s capacity to make judgments, to reason and to make decisions about their care. He cautioned that communication issues – impaired sight, hearing, or speech – did not mean that a patient was unable to make their own decisions.
He described a process for assessing capacity that includes medical, functional, and environmental factors, and shared examples from his practice. Maher underscored that among the rights of able elders is the right to make foolish choices and to choose paths that family members may not agree with.
The “Gift” of Advance Directives
A surrogate, often a family member, is the person designated to take charge when a patient no longer has the capacity to make their own decisions.
But,” cautioned Nancy Berlinger, Research Scholar at The Hasting Center, “Loss of capacity does not mean loss of rights.”
The patient’s values should still be what determine care choices. Advance directives, as well a prior conversations with the patient, can guide the decisions that a surrogate has to make.
It’s hard to be a surrogate,” Berlinger said, especially when the patient’s wishes don’t match those of the family. It is for this reason that she called advance directives “a gift to the surrogate.”
Questions about a patient’s decision-making capacity, the assessment of capacity and the implementation of choices become more layered with ethical and practical considerations near the end of life. During the afternoon conference session several case studies were explored, allowing the professionals assembled to share insights and exchange expertise.
Jewish Home’s Palliative Care Conference is an annual event, sponsored in part this year by the Joan Wachtler Research Endowment Fund and the Sally Froelich Palliative Care Endowment Fund.