A CLINICIAN??S GUIDE TO DECISION MAKING CAPACITY AND ETHICALLY SOUND MEDICAL DECISIONS

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Abstract
Competence, or decision making capacity, refers to a patient's ability to understand a situation and to make a choice in light of that understanding. It requires the physician to disclose adequate information so that the patient is able to understand and choose. The standard for determining competence is that a person is deemed competent to make medical decisions if the person is capable of giving informed consent. The crucial ethical issue is whether the patient understands and appreciates the nature of the treatment, the risks and benefits, the alternatives and the consequences. Although there is no universally accepted test of a patient's capacity to consent to treatment, the “knowledge and understanding” test offers clinicians a simple competence test that can be administered at the bedside. The physician first identifies the information needed for the patient to give informed consent. Then the physician determines the patient's understanding and appreciation of that information by means of five objective questions. Ultimately, talking to the patient is the only way to determine if the patient is capable of making a medical decision. Of particular ethical interest, however, is rehabilitation medicine's efforts to exempt itself, in the early stages of rehabilitation, from the “moral force” of informed consent. Relying on its unique characteristics as a medical specialty, and on the fact that some of its patients have suffered sudden onset of severe impairment, rehabilitation medicine appears poised to espouse the “thank you theory” of medical practice. In addition, physiatrists may have a professional obligation to fully inform patients when potentially beneficial treatment is withheld from them, such as when they are denied access to or terminated from rehabilitation.

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