A 78-year-old man is brought to the emergency department for evaluation of fever, cough, and shortness of breath. His wife reports he has been coughing for 2 days, but his breathing worsened today. The patient has a history of Alzheimer disease, with a Montreal Cognitive Assessment (MOCA) score of 24 during a visit to his primary care physician 3 weeks ago. Temperature is 38.7 C (101.7 F), blood pressure is 86/42 mm Hg, pulse is 122/min, and respirations are 20/min. Pulse oximetry shows an oxygen saturation of 92% on room air. On examination, the patient is awake, alert, and oriented but appears in mild respiratory distress. He has dry mucous membranes and bibasilar rhonchi on auscultation. He is moving all extremities, following commands, and his speech is clear. Chest x-ray shows bilateral pneumonia. The wife has the patient's living will with her, which includes signed do-not-resuscitate (DNR) and do-not-intubate (DNI) forms. Which of the following is the best next step in confirming the goals of care?

Question

A 78-year-old man is brought to the emergency department for evaluation of fever, cough, and shortness of breath.  His wife reports he has been coughing for 2 days, but his breathing worsened today.  The patient has a history of Alzheimer disease, with a Montreal Cognitive Assessment (MOCA) score of 24 during a visit to his primary care physician 3 weeks ago.  Temperature is 38.7 C (101.7 F), blood pressure is 86/42 mm Hg, pulse is 122/min, and respirations are 20/min.  Pulse oximetry shows an oxygen saturation of 92% on room air.  On examination, the patient is awake, alert, and oriented but appears in mild respiratory distress.  He has dry mucous membranes and bibasilar rhonchi on auscultation.  He is moving all extremities, following commands, and his speech is clear.  Chest x-ray shows bilateral pneumonia.  The wife has the patient's living will with her, which includes signed do-not-resuscitate (DNR) and do-not-intubate (DNI) forms.  Which of the following is the best next step in confirming the goals of care?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c1df_c24f_8f63_09619781b912_MD0005_00 This patient has bilateral pneumonia and may require intubation in the future due to respiratory distress. Although he has Alzheimer disease (AD), his cognitive impairment is mild (ie, Montreal Cognitive Assessment score of 24), and he is alert, oriented, and able to communicate. Patients with AD who have only mild cognitive impairment often retain decision-making capacity; a diagnosis of AD by itself is not a reason to assume the patient lacks capacity to give consent for medical procedures (including intubation). To determine this patient's capacity for consent or refusal for medical procedures, he requires a decision-specific capacity assessment. The 4 requisite criteria for decisional capacity are the ability to communicate the patient's choice of management options; to understand the medical condition and proposed treatment; to appreciate the consequences of treatment options (including no treatment); and to provide a rationale for the decision. If this patient meets these criteria, he should be allowed to give his own consent or refusal for treatment. (Choice A) The patient's wife (as next of kin) would serve as surrogate decision maker only if he lacked capacity and there was no advance directive to guide care. next of kin (Choice C) A physician may provide care without consent only in an emergency. In nonemergency situations, the next step is to assess the patient's decision-making capacity. (Choices D and E) Advance directives (eg, living will, do-not-resuscitate/do-not-intubate [DNR/DNI] forms) are invoked only when the patient lacks decision-making capacity. If this patient has capacity, he should give his own consent or refusal for intervention. DNR/DNI forms typically reference terminal conditions and are not necessarily intended as refusal of treatment for temporary or reversible illness (eg, pneumonia). Educational objective: Patients who have Alzheimer disease with only mild cognitive impairment often retain decision-making capacity. A decision-specific capacity assessment should be performed in nonemergency situations. References: Dementia, healthcare decision making, and disability law. (http://www.ncbi.nlm.nih.gov/pubmed/31955694)

A 78-Year-Old Man Is Brought to the Emergency Department for Evaluation