1. Decision Making at the End of Life Pain Fear Depression (SI) Isolation Cognitive loss Ethics Law Role of Psychiatrist Advance Directive SHC Guidelines

2. Situations Rights of competent patient Rights of incompetent patient –Advance Directive –Surrogate –Guardian –Unrepresented Termination of life support –Vegetative / terminal vs. limited awareness (Schiavo case) –Competent, advance directive, or surrogate –Unrepresented –Guardian

3. Ethics Personal autonomy –Right to be left alone –Right to exercise prospective autonomy Respect for life Substituted judgment Best interest

4. Law Landmark Cases –Right to consent / refuse, right to die Health Care Decisions Law (2000) –Advance Directive SHC Guidelines –Protocols integrated medical custom and the law

5. Role of the Psychiatrist Independent assessment capacity / competency Write sufficient good consultation report Indicate if / how capacity can be restored

6. Psychiatric Assessment Ability to understand & knowingly / intelligently act upon consent information using rational processes. Determine by questioning patient and doing MSE. Are there mental status deficits that cause the impaired decision? –Assess level of alertness, information processing, thought processes, ability to modulate mood and affect. Is the impairment substantial? Enduring? Treatable?

7. Advance Directive Exercise of prospective autonomy –Appoints agent –Specifies wishes agent is to carry out Do you really need one? –Best interests of another may rule –If court / guardian involved, see “Wendland.” If hospitalized, can easily appoint a surrogate

8. SHC Guidelines Online Adult patient with capacity Adult patient lacks capacity but has advance directive, surrogate, or conservator or person Adult patient lacks capacity & has no surrogate –Medical custom, second opinion, risk management, (Ethics Committee) If decision to withdraw life support, consider exclusions, refer Ethics Committee, COS, Court (patient Cs rejects) –See review of law: Conservatorship of Wendland.