When a Patient Has No Voice

1John Stroger Hospital of Cook County, Chicago, IL

Meeting: Hospital Medicine 2007, May 23-25, Dallas, Texas

Abstract number: 134

Case Presentation:

A 75‐year‐old man with a distant history of laryngeal squamous cell cancer underwent a laryngoscopy to evaluate a new left piriform mass. Complications during the procedure lead to an emergent tracheostomy, and he was admitted to the hospital, where he was diagnosed with aspiration pneumonia but quickly stabilized. His overall prognosis with a presumed new primary cancer was poor. The immediate treatment plan included transfer to a skilled nursing facility (SNF) to receive 2 weeks of parenteral antibiotics, intensive oral nursing care, and physical therapy. However, even though he was completely illiterate and, because of his laryngeal mass, unable to talk, the patient consistently and convincingly expressed his wish to go home instead. What he understood about the consequences of such a decision remained a point of contention, likely because of his difficulties in communicating his wishes. He had no established durable power of attorney and was estranged from his family, and his roommate was his closest friend. On the one hand, a consulting psychiatrist believed the patient lacked decisional capacity and recommended consultation by risk management for guardianship. On the other hand, the attending inpatient physician found that, although the patient lacked decisional capacity about treatment for some areas of his care, he retained the capacity to decide against SNF placement and to establish a power of attorney for health care. The patient chose his roommate as his surrogate decision maker, and decisions were made to finish the course of antibiotics and send the patient home for hospice care.

Discussion:

A physician's judgment about whether a patient has decision‐making capacity is based on a bedside evaluation that determines whether a patient retains 5 decision‐making skills. The patient must be able to receive and evaluate information. The patient must deliberate about information in accordance with his own values. The patient must mentally manipulate information rationally by comparing the risks and benefits of the options. And last, the patient must be able to communicate eventual treatment preference. Despite this patient's limited ability to communicate, a reiterative bedside evaluation lead to agreement among inpatient services that the patient retained these 5 skills for some aspects of his care.

Conclusions:

Whether a patient has decision‐making capacity is not an all‐or‐none diagnosis. Different decisions require different levels of decisional capacity. Although a patient may not be able to make decisions about high‐complexity issues, he or she may still be able to decide on issues of lower complexity. Within this construct, the true wishes of patients with limited communication and reasoning skills can be found. Inpatient physicians have the bedside tools to make this judgment.

Author Disclosure:

K. Lee, None; B. Lucas, None; J. Baru, None.

To cite this abstract:

Lee K, Lucas B, Baru J. When a Patient Has No Voice. Abstract published at Hospital Medicine 2007, May 23-25, Dallas, Texas Abstract 134. https://www.shmabstracts.com/abstract/when-a-patient-has-no-voice/. Accessed December 10, 2018.

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