Assessment and management of patients who lack decision-making capacity
Rosanne M. Radziewicz RN, PMHCNS-BC
Anastasia Driscoll MSN, CRNP, ACHPN
Mallika Lavakumar MD

$3.95
The Nurse Practitioner
March 2014 
Volume 39  Number 3
Pages 11 - 15
 
  PDF Version Available!

ABSTRACT
Mrs. M is a 72-year-old woman admitted with lower extremity pain and swelling. A femoral-femoral bypass was performed with consent. On the fourth day postoperatively, Mrs. M became suspicious and was noted to have auditory hallucinations (was talking with people not in the room). There was a strong odor of urine present in the room, and she complained to the nurses that men were walking into her room. She was described as demanding and struggled to leave the hospital during the night. On quick assessment, Mrs. M was neither able to explain the risks and benefits of leaving the hospital nor was she able to discuss how she would return home.Discharges that occur against medical advice (AMA) account for up to 2% of discharges each year.1,2 AMA discharges are associated with higher morbidity, mortality, and readmissions when compared to patients discharged after the goals of care were accomplished.2 Contrary to popular belief, identifying a discharge as AMA does not protect medical providers from litigation.3,4 Early readmissions following an AMA discharge can cost more than 56% of expected expenses following the initial hospitalization.5 Hospitals may, in some cases, bear the burden of readmission expenses due to declines in Medicare reimbursement for some patient populations with chronic heart and pulmonary disorders.6,7 With these considerations in mind, AMA discharges require thorough evaluation to maximize safe and ethical patient care.In cases where there is a question about the patient's ability to make an informed decision to refuse treatment, the nurse practitioner (NP) must quickly decide how to balance the patient's right to autonomy with protecting his or her best interest through beneficence (doing good) and nonmaleficence (inflicting no harm). He or she may consult with a physician to assess the patient's capacity in order to determine if the patient is able to make an "informed refusal." Whether or not a patient has the capacity to understand, make a decision,

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