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Guide to Considering Nonpsychiatric Medical Intervention Over Objection for the Patient Without Decisional Capacity

      A considerable percentage of medical inpatients are communicative but lack decisional capacity.
      • White D.B.
      • Curtis J.R.
      • Lo B.
      • Luce J.M.
      Decisions to limit life-sustaining treatment for critically ill patients who lack both decision-making capacity and surrogate decision-makers.
      • White D.B.
      • Curtis J.R.
      • Wolf L.E.
      • et al.
      Life support for patients without a surrogate decision maker: who decides?.
      These patients also often lack surrogates, particularly when they are homeless, elderly, mentally ill, or substance users.
      • White D.B.
      • Jonsen A.
      • Lo B.
      Ethical challenge: when clinicians act as surrogates for unrepresented patients.
      • Bandy R.
      • Sachs G.A.
      • Montz K.
      • Inger L.
      • Bandy R.W.
      • Torke A.M.
      Wishard Volunteer Advocates Program: an intervention for at-risk, incapacitated, unbefriended adults.
      Caring for such patients often raises ethical dilemmas, particularly when the patient refuses a proposed medical intervention. Legal and ethical guidelines regarding patients without capacity focus on treating for psychiatric illnesses,
      • Amer A.B.
      Informed consent in adult psychiatry.
      do-not-resuscitate orders,
      • Lo B.
      • Saika G.
      • Strull W.
      • Thomas E.
      • Showstack J.
      ‘Do not resuscitate’ decisions: a prospective study at three teaching hospitals.
      and withdrawal of life-sustaining therapies.
      • Smedira N.G.
      • Evans B.H.
      • Grais L.S.
      • et al.
      Withholding and withdrawal of life support from the critically ill.
      Even with these guidelines, one study found that more than 80% of decisions for patients lacking decisional capacity and without surrogates were made, often inappropriately, by physicians without hospital oversight.
      • White D.B.
      • Curtis J.R.
      • Wolf L.E.
      • et al.
      Life support for patients without a surrogate decision maker: who decides?.
      These unilateral decisions can raise multiple ethical problems, including physician bias, conflict of interest, and violation of autonomy.
      • White D.B.
      • Jonsen A.
      • Lo B.
      Ethical challenge: when clinicians act as surrogates for unrepresented patients.
      Beyond suggesting ethics committee consultation, nearly no guidance is available to the physician, or the ethics committee itself, when considering nonpsychiatric medical intervention over objection.
      • Snyder L.
      • Leffler C.
      Ethics and Human Rights Committee, American College of Physicians
      Ethics manual: fifth edition.
      • de Simone G.
      • Devereux R.B.
      • Ganau A.
      • et al.
      Estimation of left ventricular chamber and stroke volume by limited M-mode echocardiography and validation by two-dimensional and Doppler echocardiography.
      • American Medial Association
      Code of Medical Ethics.
      In addition, even when a surrogate is present, he or she would likely benefit from physician guidance to help make a sound decision.
      • American Medical Association
      Code of Medical Ethics.
      Therefore, a structured approach delineating the core questions to address in these situations can be a helpful tool for physicians and surrogates alike, even if only as preparation for an ethics consult or committee meeting, or for the ethics committee itself.
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      References

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        Life support for patients without a surrogate decision maker: who decides?.
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