This week we lost an American legend, Dolly Parton. During an appearance on Jimmy Kimmel honoring her, Jelly Roll called Dolly “the last American that everyone liked.” Similarly, both Donald Trump and the Democratic Socialists of America posted contemporaneously about how wonderful and influential she was. Nature described her as “an advocate for vaccines, public health, literacy and marginalized communities” and CNN called her the “one person who could unite a deeply divided country.”

All this got me thinking - what can Dolly teach us about ethics in modern society?

Dolly seemed to have an uncanny ability to hold convictions while simultaneously getting along with “both sides” of an issue. She was an advocate for LGBTQ+ issues but was also outspoken about her deep Christian faith. She contributed considerable philanthropic support to the development of the COVID-19 vaccine (37 papers credit the Dolly Parton COVID-19 Research Fund) despite the politicization the vaccine has faced since 2020. She played an unabashed feminist but declined to call herself one.

Some referred to Dolly as Switzerland, and at times she drew criticism for not taking sides more explicitly. She’s been called a “woman of contradictions.” However, I can’t help but wonder whether her quiet advocacy, kindness, and unwavering ability to show compassion and acceptance are lessons that could help us navigate deep divisions.

In the process of ethics consultation, we attempt to identify and name the source of the values conflict; that is, what values are in tension, and why? Through a facilitation approach, we try to help folks reach a conclusion about the conflict at hand that is ethically permissible and that also falls within the acceptable parameters of healthcare practice, institutional policy, and the law. Often, though, the most helpful piece the ethics consultation process is that it offers a space for conversation about perspectives. In other words, in discussing values, we help people talk about conflicting perspectives. That opportunity for communication is rare, especially in the busy clinical environment, and typically goes a long way in resolving the conflict at hand. I may not agree with your perspective, but if I can understand it, I am able to see you as more human, and hopefully this is reflected in the way I treat you. This is an idea that Autumn Fiester writes about quite frequently.

The most successful ethics consultations I’ve been part of have succeeded not because we’ve magically devised an ethically optimal plan, but because everyone involved felt heard and understood. Helping people to feel heard, understood, and appreciated was something Dolly excelled at.

So, perhaps in the face of this monumental loss, we can consider ways to embody Dolly, especially as we navigate conflict and disagreement.

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Welcome to Bioethics Basics. I’m Aimee – a nurse-turned-ethicist and ethics educator. My goal is to make ethics education more accessible by simplifying complex concepts in bioethics for the busy point-of-care clinician.

This post is for educational purposes only and does not constitute medical or legal advice.

Welcome to Bioethics Basics. I’m Aimee – a nurse-turned-ethicist and ethics educator. My goal is to make ethics education more accessible by simplifying complex concepts in bioethics for the busy point-of-care clinician.

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The concept of moral distress has received increasing attention in the bioethics and healthcare literature in recent years, particularly in the wake of COVID. The term was initially coined by philosopher Andrew Jameton in 1984, who described the phenomenon as “the psychological distress of being in a situation in which one is constrained from acting on what one knows to be right.” He observed nurses who had a sense of “knowing the right thing to do” but who felt unable to act upon this assessment due to internal or external constraint. In the intervening years, moral distress has been recognized as a phenomenon that occurs at all levels of healthcare, across professions and specialties. Key components involve a sense of complicity in wrongdoing associated with professional (not personal) values, a sense of lacking voice, and, typically, repeated experiences. The consequences of moral distress can be profound, and span psychological and physical sequelae including, for example, anxiety, depression, sleeplessness, and GI symptoms. Importantly, moral distress is widely recognized as a contributor to burnout, a key driver in the crisis of attrition we are currently experiencing in healthcare.

It’s critical to make a distinction between moral distress and other types of distress. For example, an argument with a colleague might trigger us to feel (rightfully) emotionally distressed. We might cry, have trouble sleeping, want to find a new job, etc. However, in an emotionally or psychologically distressing situation we are still able to fulfill our professional values and obligations. Epstein describes “the pressure to act unethically (or not to act when action is needed)” as the distinguishing features of a morally distressing saturation. This definitional clarity is important, because if everything becomes labeled moral distress, the phenomenon loses its power.

Because the antecedents of moral distress are varied and complex, addressing it is a challenging endeavor. Many interventions have focused on cultivating moral resilience, and there is some evidence to suggest that moral resilience can moderate the degree of moral distress individuals experience. However, moral resilience is an individual-level construct, and moral distress is a system-level issue. As such, there is growing attention to the need for upstream, system-level intervention. For example, we know that a perceived positive ethical climate is related to decreased levels of moral distress, and individuals who perceive higher levels of organizational support demonstrate lower levels of moral distress, burnout, and a lower likelihood of wanting to leave patient care. Thus, interventions that cultivate a more robust sense of moral community may be most effective at addressing moral distress. Even simple gestures at support can be effective. Layman and colleagues demonstrated that the use of supportive statements by mentors in challenging clinical situations can mitigate the degree of moral distress experienced by learners.

So, if moral distress is so widespread with such grievous consequences, don’t we want to eliminate it entirely? My answer to this question is no. Moral distress serves an important function, akin to a canary in the ethical coal mine. When we experience moral distress, we are identifying an ethical problem in need of addressing. We should work to minimize the sources and mitigate the consequences, to be sure, but if we stop experiencing moral distress entirely, it is not because the ethical challenges have gone away; they will persist, we will just have stopped recognizing them.

This post is for educational purposes only and does not constitute medical or legal advice.

Welcome to Bioethics Basics. I’m Aimee – a nurse-turned-ethicist and ethics educator. My goal is to make ethics education more accessible by simplifying complex concepts in bioethics for the busy point-of-care clinician.

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The idea of fiduciary duty has been top of mind for me lately, after some failures in oversight led to the closure of my son’s beloved elementary school. While fiduciary duty is often brought up in the context of legal and/or business relationships, there are similar obligations within the healthcare context.

In most Codes of Ethics, including (in the US) the AMA and ANA’s codes, a primacy is placed on the interests of the patient. For example, the AMA COE Principle VII reads: “A physician shall, while caring for a patient, regard responsibility to the patient as paramount.” Similarly, the ANA COE Provision 2 states: “A nurse’s primary commitment is to the recipient(s) of nursing care, whether an individual, family, group, community, or population.”

Underpinning this commitment is the concept of “fiduciary duty” or the obligation of clinicians to place the interests of the patient above other competing interests. While this may seem like a simple ask, conflicts of interest and commitment are commonplace in healthcare, and at times it can be difficult to disentangle the impact of various influences on a clinician’s decision-making. For example, personal profit or convenience may lead a clinician to de-prioritize the interests of the patient; this may even be done unintentionally.

In nursing specifically, fiduciary responsibilities require patient advocacy, or elevating patient-focused concerns within the interdisciplinary team. Depending on the ethical climate, this may be an endeavor that is challenging or entails some degree of risk, particularly if interprofessional collaboration is suboptimal. A nurse may be worried about creating conflict, facing retribution, or other professional consequences.

This sense of “knowing” the right thing to do but being unable to do it can give rise to moral distress. Similarly, feeling complicit in participating in a plan of care one disagrees with can result in moral distress (stay tuned for an in-depth overview of the phenomenon). Importantly, this dynamic is not isolated to nurses. Residents, fellows, or other members of the team who fall within the “middle” of the hierarchy can also feel constrained by team dynamics, making upholding fiduciary responsibilities difficult. Even attending physicians, who hold the ultimate legal authority regarding the plan of care, can be constrained by competing influences - interpersonal, professional, or otherwise.

For further reading:

Ludewigs et al (2022)

This post is for educational purposes only and does not constitute medical or legal advice.

Welcome to Bioethics Basics. I’m Aimee – a nurse-turned-ethicist and ethics educator. My goal is to make ethics education more accessible by simplifying complex concepts in bioethics for the busy point-of-care clinician.

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Paternalism involves overriding a patient’s autonomy or restricting their freedom of choice. In a problematic sense, paternalism may be enacted “for the patient’s own good” or because the clinician thinks they “know better” than the capacitated patient. (For further reading about decision-making capacity, see here.) This might occur, for example, when a physician chooses not to offer a procedure that would be medically appropriate but that the physician thinks the patient would not or should not want to pursue. This is sometimes called “hard” paternalism, and is usually not ethically justifiable. We write about an example of hard paternalism here.

There are other times, however, where paternalism may be used as a protective measure in the short term, in order to promote autonomy in the long term. This is sometimes referred to as “soft” paternalism, and usually involves overriding an incapacitated patient’s choice. For example, a patient may refuse a life-sustaining intervention (like intubation) in the context of delirium without fully understanding the implications of that refusal (likely death). This would not be considered an informed or capacitated decision, and as such overriding the patient’s refusal would prevent them from harm (in the short-term) while hopefully restoring their autonomy (in the long-term). This same logic that underpins the practice of involuntary hospitalizations, intended to protect patients who are at risk of harming themselves or others. In an ideal sense, the involuntary hospitalization serves as a temporary restriction of autonomy to avoid harm while treatment can be pursued.

There is inherent tension between the principles of autonomy and beneficence/nonmaleficence when considerations of paternalism are at play. Ultimately, we are asking how to best respect the patient’s autonomy while also trying to minimize harm or achieve a good. Overriding a capacitated patient’s informed choice is rarely, if ever, justifiable, whereas overriding an incapacitated patient’s choice may be justified in under certain conditions.

For Further Reading:

Stanford Encyclopedia of Philosophy

Kopelman (2004)

This post is for educational purposes only and does not constitute medical or legal advice.

Welcome to Bioethics Basics. I’m Aimee – a nurse-turned-ethicist and ethics educator. My goal is to make ethics education more accessible by simplifying complex concepts in bioethics for the busy point-of-care clinician.

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Reports of a well-known spine surgeon’s alleged conflicts of interest have been making the rounds on social media. Rather than diving into the specifics of this case in particular, this week I’ll review conflicts of interest, conflicts of commitment, and ways to mitigate their influence.

While both types of conflicts revolve potential obligations that could impact care, there are distinctions between the two.

Conflicts of Interest

• Involve financial or reputational stakes that could impact clinical judgment and patient care

  • Example: An attending physician’s patient is also a candidate for a clinical trial for which they are the Principal Investigator

  • Example: A hospital CEO has financial stakes in a pharmaceutical company who is conducting a clinical trial within their organization

Conflicts of Commitment

• Involve activities that may take time/attention away from patient care and therefore impact the quality of care

  • Example: A trainee earns extra money by moonlighting, but these additional shifts result in the trainee being fatigued while functioning in their primary role

Mitigation

For either type of conflict, mitigation begins with both transparency and disclosure. Even the appearance of conflict can become problematic. Organizations typically have formal disclosure processes which, while imperfect, are helpful in offering clinicians the opportunity for self-reflection, and for allowing organizations to keep track of potential conflicts. In some cases, the influence of the conflict may be too large to overcome through disclosure processes alone, in which case decisions must be made about mechanisms for protecting clinician integrity and patient care.

For Further Reading:

Fink (2020)

ANA Code of Ethics (2025): Provision 2

AMA Code of Ethics: Opinion 7.1.4

This post is for educational purposes only and does not constitute medical or legal advice.

Welcome to Bioethics Basics. I’m Aimee – a nurse-turned-ethicist and ethics educator. My goal is to make ethics education more accessible by simplifying complex concepts in bioethics for the busy point-of-care clinician.

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@aviewfromabridge"Of course, you can't live someone else's experience, but you can be proximate to it" - Marcus's View From A Bridge . @marcusmumford @Mumford & Sons . Original music @Ross Woodhead . #mumfordandsons #life #stories #imagination

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This week, I was struck by the above video - Marcus Mumford describing moral imagination, and the role it can play in helping us understand others (courtesy of @aviewfromabridge on TikTok). In it, Mumford says that people with moral imagination can “put themselves in someone else’s shoes, because of course you can’t live someone else’s experience, but you can be proximate to it if you make the effort and really listen to their stories.” He describes storytelling as a way to dignify a person’s humanity.

To me, these are power reflections on the concept of narrative, or a person’s understanding of their own story.

In Narrative Ethics, rather than focusing on principles, we use story as a starting point for understanding a patient’s lived experience, and for developing a sense of why a person has made the choices they have made. Narrative ethics is more process-based than outcome-based, focusing on voice (who is telling the story), character (who is centered within the story), plot (expectations and fractures within the story), and resolution (how the pieces fit together) (Montello, 2014)

Narrative ethics can be a powerful tool for developing empathy and compassion in the most complex situations. For example, can we re-frame the “non-compliant” patient’s decisions as choices that actually seem very reasonable, once you understand the challenges they’ve faced? Perhaps the patient who has no visitors at the bedside actually has a family that is very caring and dedicated, but working multiple jobs while caring for children outside of the hospital? The patient who presents as “difficult” and actually has a long history of being wronged by the healthcare system?

More than a simply mechanism for solving ethical problems, I find a focus on narrative can help teams with perspective taking, avoiding judgment, and checking biases. These are skills that are important to cultivate, and are particularly when tensions are high or when conflict seems intractable.

For Further Reading:

Montello 2014

Frank 2014

This post is for educational purposes only and does not constitute medical or legal advice.

Welcome to Bioethics Basics. I’m Aimee – a nurse-turned-ethicist and ethics educator. My goal is to make ethics education more accessible by simplifying complex concepts in bioethics for the busy point-of-care clinician.

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A core component of respect for persons (autonomy) involves upholding privacy and confidentiality. While these terms are often used interchangeably (or in concert), there are important distinctions.

Privacy

• Involves protecting patients from unwanted access/intrusion; a patient’s right to control access to information about themselves.

• Patients are free to choose what, and how much information they share with their healthcare providers.

• Example: A nurse accesses a “VIP” patient’s medical record because they are interested in the reason they were admitted to the hospital.

Confidentiality

• Involves the protecting patients from the disclosure of private or sensitive information; the clinician’s obligation to keep information secure and to refrain from sharing information without permission.

• Once information has been disclosed to a clinician, the obligation to maintain confidentiality applies. Under HIPAA, information is disclosed to others only on a “need to know” basis.

• Example: A physician discusses an interesting case with a peer in an elevator, including identifiable patient details, in earshot of others.

Exceptions

There are safety-related exceptions that apply. For example, if a patient discloses that they are at risk of harming themselves or others, or if a provider discovers abuse, there are mandated-reporting obligations that would permit the clinician to breach confidentiality in the interest of protecting the patient or party at risk of harm (for further reading about the Duty to Warn/ Tarasoff Case: see here) In order to avoid fracturing the clinician-patient relationship or violating trust, it is best to disclose these exceptions from the outset of the therapeutic relationship.

For Further Reading:

Folkman (2000)

This post is for educational purposes only and does not constitute medical or legal advice.

Welcome to Bioethics Basics. I’m Aimee – a nurse-turned-ethicist and ethics educator. My goal is to make ethics education more accessible by simplifying complex concepts in bioethics for the busy point-of-care clinician.

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When deciding whether to offer an intervention, clinicians commonly undertake a risk/benefit analysis. In doing so we are interested in understanding whether the foreseeable harms of an intervention outweigh the foreseeable benefits. Generally speaking, in order for an intervention to be considered ethically supportable, we want the benefit of the intervention to outweigh the risk.

In ethics, we refer to this as the principle of proportionality, or the ethical requirement that the potential “goods” of an intervention be greater than the potential “harms.”

We can conceive as harms and benefits broadly. Harms might include pain, suffering, an increased risk of morbidity/mortality, or other self-perceived harms identified by the patient. Similarly, benefits could include objective signs of clinical improvement, improved quality of life (as assessed by the patient), increased likelihood of survival, etc.

If the risks of an intervention are greater than the benefits, it would be ethically problematic to offer it: if the patient is more likely to die or experience severe life-limiting complications from a surgical procedure than to survive or experience clinical improvement, the procedure would not adhere to the principle of proportionality.

Conversely, we may want to offer an intervention that involves some degree of risk if the potential benefit is greater than that risk. For example, chemotherapy involves risk to the patient, but the benefit of treating cancer typically outweighs these risks. The greater the potential risk, the greater the potential benefit ought to be.

For further reading:

Fins & Miller (2020)

Hermerén (2011)

This post is for educational purposes only and does not constitute medical or legal advice.

Welcome to Bioethics Basics. I’m Aimee – a nurse-turned-ethicist and ethics educator. My goal is to make ethics education more accessible by simplifying complex concepts in bioethics for the busy point-of-care clinician.

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In clinical practice, appealing to claims of “futility” is relatively commonplace. As an ethics consultant, I have often received consult requests due to perceived “futile care.” Typically, these involve cases where the clinical team has assessed that a critically ill patient is approaching end-of-life, yet the patient’s family has not yet come to terms with this fact – these often manifest as conflicts around code status (i.e. full code versus DNR/DNI).

Despite the intuitive appeal of the term, for many years bioethics scholars have cautioned against using the word except in very particular circumstances. This is, in part, due to challenges with definitional clarity – what do we mean by futile? According to whom? Who gets to decide?

For example, a clinician may claim that continued ICU care is “futile” in the sense that the patient is unlikely to survive to ICU discharge, however the patient’s family may contend that any additional time with a loved one is worthwhile and therefore, not futile. In other words, the term is inherently subjective and value laden.

Some have attempted to draw distinction between qualitative and quantitative futility (see Schneiderman et al., 1990), however even these attempts don’t avoid issues with subjectivity and different value judgments.

This subjectivity is problematic in part because claims of futility may be used to justify unilateral withdrawing or withholding of interventions under the guise of objectivity. It is true that clinicians are not obligated to provide interventions that are assessed to be more harmful than helpful, or those for which the burdens outweigh the benefits. However, in many cases QOL judgments hinge on an assessment of quality-of-life, which is a notoriously subjective one and one in which clinicians and patients often disagree. Ultimately, an assessment of acceptable quality-of-life ought to be up to the patient (or surrogate, by extension) to decide. That said, clinicians should avoid providing treatments where it is clear that the risks outweigh the proportional benefits.

What terms can be used instead?

In a landmark policy paper (widely referred to as the 5-Society Statement), the ATS/AACN/ACCP/ESICM/SCCM recommend only using the term futile in “the rare situations in which surrogates request interventions that simply cannot accomplish their intended physiologic goal.” In other words, appealing to physiologic futility remains ethically appropriate, when clinically indicated.

In addition, the 5-Society Statement recommends using “potentially inappropriate treatment” in situations when “treatments… have at least some chance of accomplishing the effect sought by the patient, but clinicians believe that competing ethical considerations justify not providing them.” Others have used the phrase “nonbeneficial treatment” in the case that “the burden of treatment outweighs any benefit to the patient.”

In most cases where potentially inappropriate or nonbeneficial treatments are creating conflict, an ethics consult may be appropriate. The 5-Society Statement outlines an escalation process that ought to be followed in order aid in resolving intractable conflict.

Additional Reading:

Bosselet et al. (2015)a

Bosselet et al. (2015)b

Bosselet et al. (2018)

Janse et al. (2004)

Lo et al. (2022)

Schneiderman & Jonsen (1990)

This post is for educational purposes only and does not constitute medical or legal advice.

This marks my final post for 2025. I appreciate your support and am grateful for the community we are building in this space. I look forward to engaging with you in the New Year - let me know what topics you’d like to see covered next!

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Bioethical Principles & Principlism

While there are many approaches to navigating ethical conflict, principlism is a commonly used framework. Widely attributed to Tom Beauchamp and James Childress, principlism articulates four major bioethical principles:

1. Autonomy: Respect for persons; the right to self-determination

   1. Related concepts include the process of informed consent, surrogate decision-making, and advance care planning as mechanisms of respecting and/or extending a person’s autonomous preferences

2. Beneficence: the obligation to do good

   1. Sometimes called a “positive obligation,” meaning we are called to take action to achieve a good on behalf of the patient

3. Nonmaleficence: the obligation to avoid, or minimize, harm

   1. In contrast, this is a “negative obligation” in that we must sometimes not act in order to avoid a harm

4. Justice: fair and equitable treatment; fairness in distribution of goods, risks and benefits

   1. Considerations of justice are at the core of decisions related to resource allocation (think ECMO, organ donation, Crisis Standards of Care algorithms, etc.)

These principles are meant to represent moral norms - guidelines that are thought to have widespread societal support and therefore can be useful in guiding clinical care. For example, most people agree that killing is wrong and would thus be a violation of the principle of non-maleficence. The principles are meant to be non-hierarchical, meaning no one principle automatically overrides any of the others. Of course, societal values change and evolve over time and are not constant across cultures, so therefore the way each of the principles is prioritized in a given situation is context-dependent.

Important Points

• Principles can be useful in articulating the source of an ethical conflict or tension (or simply in communicating about the “thing” you are worried about), however principles alone cannot provide clear guidance about the “right” thing to do. This is where other contextual features and additional ethical analysis can be helpful (including specifying and weighing ethical principles - see below for further reading on this).

• A true ethical dilemma occurs when two principles come into conflict and there is no clear resolution. For example: there is one ECMO circuit available and two patients who need it. We can decide how to most justly allocate the ECMO and provide a “good” to the patient who receives it, however the other patient will inevitably be harmed (conflict between beneficence and non-maleficence).

For Further Reading:

Beauchamp & Childress (2019)

This post is for educational purposes only and does not constitute medical or legal advice.

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Surrogate Decision-Making

When a patient has been assessed to lack decision-making capacity, we turn to a surrogate decision-maker to make healthcare-related decisions on their behalf.

Types of Surrogates

• Healthcare Proxy Agent/ Durable Power of Attorney for Healthcare (DPOA-H)

  • Legally authorized surrogate, appointed by the patient

  • Typically able to make any decision the patient would be able to make for themselves.

  • Terminology varies by state

• Next of Kin:

  • Some states have a “next of kin hierarchy,” wherein the clinical team can turn to the next-closes relative to make decisions on the patient’s behalf by default

  • Notably, some states, like MA, do not have a next of kin hierarchy so a healthcare proxy or legal guardian is required

• Legal Guardian:

  • Appointed by a court in the context of incapacity. Initially limited in decision-making scope (“ordinary treatment” decisions)

  • Often “time-limited” to start

  • Courts attempt to appoint a family member or close friend, but in the absence of these a “Corporate Guardian” may be appointed - often an attorney

  • Typically a court-authorized expansion of guardianship authority is required for decisions about “extraordinary treatment” such as changes in code status

Once a surrogate has been identified, what standard ought to be used to make decisions? If an advance directive is available, this should be used to inform decision-making. Beyond this, there are two basic standards we turn to, based on how much knowledge we have about the patient.

• Substituted Judgment Standard

  • This standard can be applied when we have some sense of the patients goals/values/preferences and/or what is important to them.

  • Using this standard, we ask: What would the patient choose in this instance, based on what I (as the surrogate) know about them and their goals/values/preferences?

• Best Interests Standard

  • This standard typically applies where we are uncertain about the patient’s goals/values/preferences, and/or they haven’t been able to express them. For example, this standard is more frequently used in pediatrics, where patients have less life experience than adults.

  • Under this standard, we might say: I (the surrogate) am not sure what the patient would want in this instance… What would a reasonable person want? What choice maximizes benefits and minimizes harms for the patient?

Important Points

• Decisions are not based on what the SURROGATE would want for themselves. It is often helpful to remind surrogate decisions makers of this fact, as it is quite common for the surrogate to misunderstand their role or to make decisions from a place of anticipatory grief, rather than based an understanding of the patients’s goals, values, and preferences.

• Situations may arise where the surrogate is requesting treatments that do not seem aligned with the patient’s preferences (ex: surrogate requests full code while existing MOLST says Do Not Resuscitate). In these situations, ethics consultation may be helpful.

For Further Reading:

Pope (2025)

Levi et al. (2023)

This post is for educational purposes only and does not constitute medical or legal advice.

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I want to follow up my recent discussion of advance directives by exploring decision-making capacity. In its simplest form, decision-making capacity has to do with whether or not a patient is able to make a healthcare-specific decision for themselves. If a person is found to lack decision-making capacity, we turn to a surrogate decision-maker to decide on their behalf.

In order for a surrogate decision-maker to be “invoked” or “activated,” we must first formally assess that a patient is unable to make the particular medical decision in question for themselves due to incapacity.

It is common to hear capacity and competence used interchangeably, however there are important clinical and legal distinctions between the terms.

Decision-making capacity

• Time specific (morning vs. evening; medicated vs. unmedicated)

• Decision-specific (What would you like for breakfast? versus Do you consent to a high-risk surgical procedure?)

• Clinical assessment typically determined by an attending physician (some states allow APPs)

Competence

• Applies globally

• Decided by judge

• Usually requires the appointment of a legal guardian to serve as a surrogate

How do we decide?

A capacity assessment can be conducted by any trained MD/provider, though complex cases are often referred to Psychiatry for expert assessment. A common assessment framework involves the Applebaum criteria, in which the provider assesses the following:

• Understanding

  • Does the patient grasp the fundamental meaning of the information communicated?

• Reasoning

  • Can the patient compare options and justify a choice based on logical reasoning?

• Appreciation

  • Does the patient recognize how their condition and choices affect them personally?

• Expression of a choice

  • Can the patient clearly express a treatment decision?

Important Points

• Increased risk/complexity of decision = increased stringency of capacity assessment

• Capacity is fluid and should be assessed regularly; it can fluctuate over the course of a day

• Patients may retain capacity for certain, simpler decisions while not having capacity for more complex or higher-risk decisions

• Capacity is not all or nothing - the question we should be asking is not “does this person have capacity?” but instead, “does this person have capacity for THIS decision?”

For Further Reading:

Libby et al. (2023)

Appelbaum (2007)

Tunzi (2001)

Stay tuned for an upcoming post about the related topic of surrogate decision-making and the standards we use in deciding for others. What topics would you like to see covered next?

This post is for educational purposes only and does not constitute medical or legal advice.

Advance Directives

Broadly speaking, advance directives are a way for patients to make their goals and preferences known in the event that they lose decision-making capacity at some future date.

Types of Advance Directives

• Treatment Directive: Typically include a written summary of the patient’s preferences regarding potential future treatments, including life sustaining treatments like CPR and intubation, as examples.

  • Living Will: A written narrative about patient preferences, often completed with an attorney. May include the appointment of a surrogate in some cases (see Proxy Directive below).

    • Example Living Will

  • POLST: A checklist-style document completed with a provider (MD, APRN, PA) that indicates patient preferences regarding specific treatments (CPR, intubation, dialysis, etc).

    • Example POLST form

• Proxy Directives: Used to appoint a surrogate decision-maker who is tasked with making decisions on behalf of the patient in the event that the patient loses decision-making capacity. The surrogate may also be referred to as an “agent.”

  • Healthcare Proxy

    • Example Form

  • Durable Power of Attorney for Health Care

    • Example Form

It is important that patients have both types of directives. Having an appointed surrogate decision-maker does not ensure that the surrogate knows what the patient would want. Conversely, having a treatment directive without appointing an authorized surrogate may leave the patient without a decision-maker in the event of incapacity.

For Further Reading:

Mayo Clinic

National Institute on Aging

This post is for educational purposes only and does not constitute medical or legal advice.