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U HAVE AN ADVANCE DIRECTIVE? U HAVE A WILL? R U IMMORTAL? U KNOW MR. WENDLAND?

U HAVE AN ADVANCE DIRECTIVE? U HAVE A WILL? R U IMMORTAL? U KNOW MR. WENDLAND?. GERIATRIC FORENSIC PSYCHIATRY. AUTONOMY VS DEPENDENCY DEMENTIA, DEPRESSION, DRUGS FUNCTION, FINANCES, FAMILY ISSUES AT THE END OF LIFE DECISION TO STOP TREATMENT / NUTRITION

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U HAVE AN ADVANCE DIRECTIVE? U HAVE A WILL? R U IMMORTAL? U KNOW MR. WENDLAND?

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  1. U HAVE AN ADVANCE DIRECTIVE? U HAVE A WILL? R U IMMORTAL? U KNOW MR. WENDLAND?

  2. GERIATRIC FORENSIC PSYCHIATRY • AUTONOMY VS DEPENDENCY DEMENTIA, DEPRESSION, DRUGS FUNCTION, FINANCES, FAMILY • ISSUES AT THE END OF LIFE DECISION TO STOP TREATMENT / NUTRITION DIE IN HOSPITAL / HOME / HOSPICE COMFORT CARE LEGAL MATTERS • MEDICAL CAPACITY / LEGAL COMPETENCY SUBSTITUTED JUDGMENT / BEST INTEREST STANDARD • TESTAMENTARY CAPACITY • UNDUE INFLUENCE • ELDER ABUSE See http://forensicpsychiatry.stanford.edu

  3. ETHICAL ISSUES • SELF-DETERMINATION • PERSONAL RESPONSIBILITY • INTERVENTION LIMITED BY NECESSITY • RESPECT FOR PATIENT WISHES • PSYCHIATRIC ETHICS: CLINCAL VS. FORENSIC

  4. THE PSYCHIATRIST • ASSESS MEDICAL CAPACITY • WRITE LEGALLY SUFFICIENT NOTE • OFFER CLINICAL RECOMMENDATIONS • OFFER FORENSIC OPINION IF REQUESTED CONSISTENT WITH LEGAL REASONING

  5. PROBATE CODE SEC. 810 • 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?

  6. PROBATE CODE SEC. 812 • 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

  7. Probate Code Sec. 813MEDICAL COMPETENCY • 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

  8. PROBATE CODE SEC. 811 • Alertness and attention a) Orientation, level of arousal, ability to attend • 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 • Thought processes Hallucinations, delusions , repetitive thoughts, disorganized thinking • Ability to modulate mood and affect • Substantial impact on decision

  9. PROBATE CODE SEC 3204 TO REQUEST COURT ORDER: SUBMIT PETITION: • NATURE OF MEDCAL CONDITION • SPECIFIC TREATMENT RECOMMENDED • THREAT TO PATIENT IF NOT AUTHORIZATION • PROBABLE OUTCOME IF TREATMENT AUTHORIZED • AVAILABLE ALTERNATIVES • SPECIFIC EFFORTS MADE TO OBTAIN CONSENT • NAME OF PERSON TO GIVE INFORMED CONSENT • SUPPORTING SEC. 811 FINDINGS AND CONCLUSIONS

  10. PROBATE CONSERVATORSHIP SEC 2356.5 DEMENTIA POWERS • 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

  11. Advance Directive PROBATE CODE Sec. 4700 • AN EXERCISE IN PROSPECTIVE AUTONOMY • TWO PARTS (a) POWER OF ATTORNEY FOR HEALTH CARE (b) LIVING WILL • REQURIES TWO WITNESSES OR NOTARIZATION • FILE DOCUMENT WITH DOCTOR / HOSPITAL • REVOCABLE AT WILL

  12. SHC Guidelines Online • 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

  13. TESTAMENTARY CAPACITYProbate Code Sec. 6100.5 • 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

  14. UNDUE INFLUENCESEC. 1575 CIVIL CODE • 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

  15. ELDER ABUSE W&I Code Sec. 15600-15657.3 • 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. • 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 • PENALTY: JAIL, FINE, CIVIL SUIT, NOT INSURABLE

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