How to determine a Pt is incompetent?

[blackvans1234]

Hey all, just wondering how your facility determines if a Pt is incompetent to make decisions regarding their care.

I work as a PCT in an inpatient rehab, and Mr John Doe had a stroke during or after a procedure. Mr Doe now has aphasia and his vocabulary is extremely limited. His main phrase is "No I can't do that" And some other select phrases. The Pt can not write or express their needs in any other way.

The Patient has been refusing to eat meals, refusing to drink water etc.

They tried to gain IV access last night and could not. The next step would be either NG tube or PICC line I assume.

There are no IV teams at my hospital, and the Nurse trying for access is very experienced.

Now this Patient is not ''incompetent'' , but their needs can not be expressed by them. And their cognitive ability may be compromised.

How would your facility handle this situation?

I assume talk it over with the family, and then if they approve we can move forward with a PICC / G tube?

I'm not sure what the Neurologist has said about the patient's cognition.

Thanks!

[jadelpn, LPN, EMT-B]

This is something that you should bring to the attention of the primary RN, (who I am sure is realizing that this patient is not communicating appropriately) and perhaps ask if there's going to be a family meeting with social work on how to proceed with care on this patient. There's a whole legality to incompetence, that needs to come from a multi-discipline meeting. You may certainly ask if you can be involved in this process, as a PCT who has attempted to feed, bathe, and otherwise attempt to care for this patient.

Sometimes, patients have advance directives that we are not all a party to. Conversations with family as to how much intervention a patient may or may not want. This patient may be "communicating" in the only way they can at their current functional level, and that is OK. It may not be what one would consider for their own selves or their own family, but seems to me that this patient is being clear on his own wants--and that doesn't mean that his mind is not sharp as a tack.

Part of our advocacy needs to be suppporting a patient who is choosing not to continue with care. One of the saddest things is when family decides otherwise. But the patient chose a health care advocate (hopefully). If not, then it is up to the next of kin to decide where to go from here.

Questioning competency comes from a variety of levels. But seemingly, if the patient is actively refusing to eat or participate in rehab goals, the patient is speaking loud and clear.

[KelRN215, BSN, RN]

For a true competency eval, the patient would need to be evaluated by psych and, if he is found to be incompetent, a judge would need to grant a family member guardianship/power of attorney. If the patient has an Advanced Directive or Health Care Proxy on file, this is a situation where those documents could come into place.

I have only actually seen it happen once with someone who was previously his own legal guardian where the case went to court and a guardian was appointed. I work in pediatrics and in most cases where children are not competent to be their own legal guardians when they turn 18, it's pretty straight forward. Even in those cases, the family needs to go to court to be granted guardianship and they need to pay for a lawyer who represents the child as well.

[P B and J]

I learned about competency, or lack of, like this. Legally for someone to be competent there are several requirements: First, the person must have the treatment options explained to them in simple to understand terms (usually at a 5th grade level or below). Second, they must be able to understand these options. Third, they must be able to rationalize and think about the options to decide what course of action they wish to take. And lastly, they must be able to make their wishes known. This last part is where most competency is decided, but it doesn't have to be verbal, turning their head away when food/drink, etc. is offered can be a clear indication of wishes, even without words. Competency is a tricky issue, especially if family decides to override the express wishes of their loved ones, very sad.