Issues in Geriatric Care: Medical Decision-Making.

Medical decision-making capacity (DMC), which is determined by clinicians, is the ability of patients to understand information about options for their care, express a choice among those options, appreciate the benefits and risks of those options, and explain the reasoning behind their particular choice. DMC differs from competence, which is a legal concept concerning the mental ability of individuals to be responsible for their decisions and actions. A variety of instruments can be used to assess DMC. If it is determined that a patient lacks DMC, clinicians have an ethical obligation to seek out a surrogate decision-maker. Surrogates ideally should be chosen by the patient in advance. In the absence of such designated surrogates, state laws outline who can serve in this role. Clinicians should seek informed consent for treatment, except in emergency situations. A shared decision-making process is ideal. This involves sharing treatment options with patients and supporting them in making choices based on their values and preferences. The best case/worst case approach to explaining treatment options is useful for helping patients to make appropriate choices in difficult situations. Palliative care teams and family meetings also can be helpful in facilitating decision-making.