Case #8
Family Decisions

Case Goals
  • Assess the patient's decision-making capacity while he is alert
  • Navigate family conflict about treatment decisions
  • Apply principles of informed consent appropriately
  • Understand surrogate decision-making when advance directives are absent

    • Goals

  • Assess the patient's decision-making capacity while he is alert
  • Navigate family conflict about treatment decisions
  • Apply principles of informed consent appropriately
  • Understand surrogate decision-making when advance directives are absent
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    Welcome! I am Dr. Alfred Schmurtz III, and today we explore one of medicine's most challenging scenarios involving informed consent, advance directives, and family dynamics. Our case involves Harold Thompson, an 82-year-old gentleman with advanced pancreatic cancer who was recently admitted for failure to thrive and altered mental status. His local son Michael has been his primary caregiver since his wife Martha died two years ago. Harold's mental capacity seems to fluctuate day by day. You are the attending physician meeting with Harold and Michael in the hospital to discuss his condition and goals of care. You'll need to assess capacity, understand his values and what matters most to him, and navigate the complex process of informed consent with a patient whose decision-making ability varies. Your goal is to ensure that Harold's wishes are respected while also addressing the concerns of his family members, particularly his daughter Sarah who is arriving later today. Let's begin by meeting with Harold and his son Michael. Why don't you start by asking about Mr. Thompson's current condition and what they understand about his diagnosis?

    Case Complete!

    High Yield points about this case:

    • Decision-making capacity requires four elements: understanding, appreciation, reasoning, and choice communication.
    • Informed consent is a process requiring disclosure, understanding, capacity, and voluntariness - not just a signed document.
    • Only 30% of Americans have completed advance directives, creating frequent surrogate decision-making scenarios.
    • Surrogate decision-maker hierarchy typically follows: spouse, adult children, parents, adult siblings, other relatives.
    • The 'substituted judgment' standard asks what the patient would have wanted, while 'best interest' asks what's objectively best for the patient.
    • Pancreatic adenocarcinoma has a 5-year survival rate of approximately 5%, making goals of care discussions crucial.
    • Therapeutic privilege allows withholding information only when disclosure would severely harm the patient or undermine decision-making capacity.