Transcript Forensic Issues at the End of Life

U HAVE AN ADVANCE DIRECTIVE?
U HAVE A WILL?
R U IMMORTAL?
U KNOW MR. WENDLAND?
GERIATRIC FORENSIC PSYCHIATRY
1.
AUTONOMY VS DEPENDENCY
DEMENTIA, DEPRESSION, DRUGS
FUNCTION, FINANCES, FAMILY
2.
ISSUES AT THE END OF LIFE
DECISION TO STOP TREATMENT / NUTRITION
DIE IN HOSPITAL / HOME / HOSPICE
COMFORT CARE
LEGAL MATTERS
2.
MEDICAL CAPACITY / LEGAL COMPETENCY
SUBSTITUTED JUDGMENT / BEST INTEREST STANDARD
3.
4.
5.
TESTAMENTARY CAPACITY
UNDUE INFLUENCE
ELDER ABUSE
See http://forensicpsychiatry.stanford.edu
ETHICAL ISSUES
1.
2.
3.
4.
5.
SELF-DETERMINATION
PERSONAL RESPONSIBILITY
INTERVENTION LIMITED BY NECESSITY
RESPECT FOR PATIENT WISHES
PSYCHIATRIC ETHICS: CLINCAL VS. FORENSIC
THE PSYCHIATRIST
1.
2.
3.
4.
ASSESS MEDICAL CAPACITY
WRITE LEGALLY SUFFICIENT NOTE
OFFER CLINICAL RECOMMENDATIONS
OFFER FORENSIC OPINION IF REQUESTED
CONSISTENT WITH LEGAL REASONING
PROBATE CODE SEC. 810
1.
2.
REBUTTABLE PRESUMPTION OF CAPACITY
DOES THE PERSON SUFFER FROM MENTAL
DEFICITS SO SUBSTANTIAL AS TO BE DEEMED
TO LACK LEGAL CAPACITY TO DO AN ACT?
PROBATE CODE SEC. 812
1.
2.
3.
PERSON LACKS CAPACITY TO MAKE DECISION IF
DOES NOT HAVE ABILITY TO:
COMMUNICATE A DECISION
UNDERSTAND AND APPREICIATE:
a) RIGHTS, DUTIES, RESPONSIBILITIES, CONSEQUENCES
b) RISKS, BENEFITS, REASONABLE ALTERNATIVES
Probate Code Sec. 813
MEDICAL COMPETENCY
1.
2.
3.
RESPOND KNOWINGLY AND INTELLIGENTLY
TO QUERIES ABOUT MEDICAL TREATMENT
PARTICIPATE IN TREATMENT DECISION BY
MEANS OF A RATIONAL THOUGHT PROCESS
UNDERSTAND ALL … BASIC MEDICAL
[INFORMED CONSENT] INFORMATION
PROBATE CODE SEC. 811
1. ALERTNESS AND ATTENTION
A) ORIENTATION, LEVEL OF AROUSAL, ABILITY TO ATTEND
2. INFORMATION PROCESSING
A) IMMEDIATE RECALL, SHORT-TERM, LONG-TERM MEMORY
B) ABILITY TO UNDERSTAND AND COMMUNICATE
C) RECOGNITION OF FAMILIAR OBJECTS AND PERSONS
D) UNDERSTAND AND APPRECIATE QUANTITIES
E) ABILITY TO PLAN, ORGANIZE, CARRY OUT ACTIONS IN
RATIONAL SELF-INTEREST
F) ABILITY TO REASON LOGICALLY
3. THOUGHT PROCESSES
HALLUCINATIONS, DELUSIONS , REPETITIVE THOUGHTS,
DISORGANIZED THINKING
4. ABILITY TO MODULATE MOOD AND AFFECT
5. SUBSTANTIAL IMPACT ON DECISION
PROBATE CODE SEC 3204
TO REQUEST COURT ORDER: SUBMIT PETITION:
(a) NATURE OF MEDCAL CONDITION
(b) SPECIFIC TREATMENT RECOMMENDED
(c) THREAT TO PATIENT IF NOT AUTHORIZATION
(d) PROBABLE OUTCOME IF TREATMENT AUTHORIZED
(e) AVAILABLE ALTERNATIVES
(f) SPECIFIC EFFORTS MADE TO OBTAIN CONSENT
(g) NAME OF PERSON TO GIVE INFORMED CONSENT
(h) SUPPORTING SEC. 811 FINDINGS AND CONCLUSIONS
PROBATE CONSERVATORSHIP
SEC 2356.5 DEMENTIA POWERS
1.
2.
3.
4.
5.
6.
7.
8.
PEOPLE WITH DEMENTIA NEED CONSERVATOR
CLEAR AND CONVINCING STANDARD
REVIEWED BY COURT EVERY TWO YEARS
PROTECT PERSON / PRESERVE ESTATE
INFORMED CONSENT GIVEN BY CONSERVATOR
PERMIT PLACEMENT IN SECURE FACILITY
PERMIT MEDICATIONS TO TREAT DEMENTIA
CONSERVATORSHIP OF WENDLAND
Advance Directive
PROBATE CODE Sec. 4700
1.
2.
AN EXERCISE IN PROSPECTIVE AUTONOMY
TWO PARTS
(a) POWER OF ATTORNEY FOR HEALTH CARE
(b) LIVING WILL
3.
4.
5.
REQURIES TWO WITNESSES OR NOTARIZATION
FILE DOCUMENT WITH DOCTOR / HOSPITAL
REVOCABLE AT WILL
SHC Guidelines Online
1.
2.
ADULT PATIENT WITH CAPACITY
ADULT PATIENT LACKS CAPACITY BUT HAS
ADVANCE DIRECTIVE, CONSERVATOR OF
PERSON, OR SURROGATE
(a) BEST INTERESTS INFORMED SUBSTITUTED JUDGMENT
(b) IF CONSERVED, SEE WENDLAND LIMITATION
3.
ADULT PATIENT LACKS CAPACITY & HAS NO
SURROGATE DECISION MAKER
(a) MEDICAL CUSTOM / ETHICS COMMITTEE / COS/ COURT
(b) IF PATIENT OBJECTS – SEE PROTOCOL
(c) TO WITHDRAW LIFE SUPPORT – SEE PROTOCOL
(1) IF PATIENT OBJECTS, COURT ORDER
TESTAMENTARY CAPACITY
Probate Code Sec. 6100.5
1.
2.
3.
4.
5.
UNDERSTAND NATURE OF TESTAMENTARY ACT
KNOW EXTENT OF PROPERTY
KNOW LIVING DESCENDANTS AND THOSE
WHOSE INTERESTS WILL BE AFFECTED
NO PROVISION IN WILL PRODUCT OF DELUSION
NO PROVISION IN WILL PRODUCT OF MENACE,
DURESS, FRAUD, OR UNDUE INFLUENCE
UNDUE INFLUENCE
SEC. 1575 CIVIL CODE
1.
2.
3.
USE, BY ONE IN WHOM CONFIDENCE OR
AUTHORITY IS PLACED BY ANOTHER OR WHO
HOLDS REAL OR APPARENT AUTHORITY OVER
ANOTHER, OF SUCH CONFIDENCE OR
AUTHORITY TO OBTAIN UNFAIR ADVANTAGE;
TAKING UNFAIR ADVANTAGE OF ANOTHER’S
WEAKNESS OF MIND
TAKING GROSSLY OPPRESSIVE AND UNFAIR
ADVANTAGE OF ANOTHER’S NECESSITIES OR
DISTRESS
ELDER ABUSE
W&I Code Sec. 15600-15657.3
1.
2.
3.
AGE 65
PHYSICIAN IS MANDATED REPORTER
OBSERVES OR HAS KNOWLEDGE OF:
a) PHYSICAL ABUSE, ABANDONMENT, ABDUCTION
b) ISOLATION, FINANCIAL ABUSE, NEGLECT.
c) NO REQUIREMENT TO INVESTIGATE SUSPICION.
4.
EXEMPTION (IF MEET ALL CRITERIA BELOW):
a) INCIDENT REPORTED BY THE ELDER
b) NO CORROBORATION
c) MENTAL ILLNESS OR DEMENTIA
d) REASONABLY BELIEVES ABUSE DID NOT OCCUR
5.
PENALTY: JAIL, FINE, CIVIL SUIT, NOT INSURABLE