Incompetent to Make Decisions

Cowboyardee · Nov 7, 2018

The process of declaring a person incompetent to make their own healthcare decisions as well as the rights of a patient deemed incompetent depends mostly on the laws in the state in which you live. Often, an incompetent person cannot entirely refuse interventions that their designated decision-maker declares to be in their best interests.

With that said, most of the time a patient who lacks decision-making capacity refuses some intervention, the issue should be brought up to the patient's provider. This is because not all ordered interventions have more benefits than risks on a non-compliant or combative patient. Performing orthostatic blood pressure checks on a patient who is combative when touched and refuses to stand doesnt make a whole lot of sense. Et cetera.

In other words, just because you legally can override a patient's autonomy doesn't always mean that you should.

PeakRN · Nov 8, 2018

First and foremost I would talk to your ethics and compliance, risk management, and legal teams. Some of this varies by state, and what hospital policies you already have in place. I'll give you a few of my thoughts but this should in no way be construed as advice on how to practice nor legal advice.

Every so often at our facility we come across patients who are evaluated by our psychiatrist and deemed "incompetent to make decisions." These patients can sometimes be alert and oriented or alert and confused.

Patients can be alert and able to answer orientation questions but also not able to fully understand the risks and benefits of their care. They may be psychotic, delusional, paranoid, have significant intellectual disability, and so on. Evaluation is much deeper than their level of consciousness and ability to answer basic orientation questions.

Typically they are patients who have an extended length of stay at the hospital because they are non-compliant with treatments and medications. Sometimes, they have a designated health-care proxy who can offer consent for treatment but they are not there 24/7.

Ideally the proxy would be contacted before any decision making but this isn't always possible or reasonable. Major decisions, like for placement or elective surgery, would need to be discussed with the proxy whenever possible, but things like giving antiemetics or performing emergent treatments can be reasonable to perform if their isn't a prior discussion with the proxy and they are not readily available.

In terms of ethics, does the patient, if deemed incompetent, still have the right to refuse medications/treatments? Or in that case can they be forced against their will to comply. If a patient refuses medications/blood draws, e.t.c. I educated them and if they still refuse, document and notify the physician.
But do they have the right to refuse if they are diagnosed as incompetent?

Patients who are not capable of being their own decision makers are not capable of refusing care, whether that be from short term medical/mental health holds or legal court orders.

The results of performing the action against their will should also be weighed against the risks and the benefits, there is no way to make a global statement on this. Ideally these situations would have been discussed with the proxy, if there is one, prior to the event occurring. The urgent/emergent nature of the event should of course be weighed against the need and the ability to consult the medical team, proxy, ethics, and so on...