Volume 196 - Issue 5
Competence and capacity at the end of life: uneasy paternalism
Authors: Sharon G Reutens and Carmelle Peisah
Med J Aust 2012; 196 (5): 312. || doi: 10.5694/mja11.11596
Published online: 19 March 2012
Published online: 19 March 2012
To the Editor: Le and Chapman’s article1 on capacity at the end of life raises a number of timely issues, given our ageing population and the autonomous rights of individuals in end-of-life decision making.2
The authors made a best-interests decision, based on the patient’s humanity and their responsibility not to let him die “alone, cold and probably in pain”, contrary to his “decision” to die what would not be “a good death”. This stance can be problematic because best interests or good death are entirely subjective, and doctors who provide treatment to a competent patient may be committing trespass.3 Thus, the question of whether he was capable of making a decision to die “a bad death” is possibly more crucial.
Structured capacity assessment is beneficial for the peace of mind of clinicians, patients and family. This patient lay on the floor “because he wished to do so” — a “limited realistic choice”. He was delirious and therefore deemed incompetent. Did the delirium affect his ability to weigh the pros and cons of staying on the floor and refusing hospital admission? Assessment of capacity to consent to medical treatment involves determining whether the patient is capable of understanding the ramifications of treatment and its alternatives (including no treatment). His premorbid choices (precedent autonomy)4 of living a squalid, isolated existence and refusing treatment for some time must also be noted. Yet capacity is dynamic and can change over time.
Careful capacity assessment can justify decisions made on behalf of patients.
Competing interests
The authors have received honoraria from Pfizer and Alzheimer’s Australia for speaking engagements.
References
- Le BH, Chapman MD. Competence and capacity at the end of life: uneasy paternalism. Med J Aust 2011; 195: 476-477. 0_CHDFHEII
- O’Neill N, Peisah C. Capacity and the law. Sydney: Sydney University Press, 2011. http://www.austlii.edu.au/au/journals/SydUPLawBk/2011/1.html (accessed Dec 2011).
- Ryan CJ, Callaghan S. Legal and ethical aspects of refusing medical treatment after a suicide attempt: the Wooltorton case in the Australian context. Med J Aust 2010; 193: 239-242. 0_pgfId-2503980
- Davis JK. The concept of precedent autonomy. Bioethics 2002; 16: 114-133. 0_CBBJBIIJ