(114) A Matter of Capacity: Code Status, Professional Guardianship, and the Role of C-L Psychiatry in Determining Goals of Care

Abstract:

Background: Professional guardians are paid officials selected by a judge to make medical decisions on a patient’s behalf. Limited literature exists about professional guardians making end-of-life decisions for patients (Cohen 2019). We present the case of a patient with a devastating neurologic injury, assigned a professional guardian during a prolonged admission and discuss difficulties navigating decisions.

Case: Mr. K is a 38-year-old with a history of methamphetamine and opioid use disorders, right MCA stroke, and substance-induced bipolar disorder. He was discovered unresponsive and brought to the hospital. He was found to have a C2-T1 epidural abscess, leading to ventilator dependence and quadriplegia.

A professional guardian was assigned after unsuccessful attempts to reach family. Mr. K often became bradycardic and once suffered a traumatic resuscitation during wound care for a sacral ulcer, leading to frequent dressing change refusals. Psychiatry was consulted to assess his decision-making capacity (DMC) to refuse dressing changes, determining he did have DMC. Despite this, the professional guardian consented to dressing changes on his behalf. After a later discussion with palliative care, Mr. K requested to update code status to DNR/DNI. His guardian requested documentation from both psychiatry and primary medical teams stating he had DMC, which was provided. About a week later, Mr. K requested his code status be switched back to full code. His guardian agreed to this change to escalate care without involving psychiatry.

Discussion: Mr. K’s deliberation over his code status is consistent with literature showing patients often change their wishes over time regarding life-sustaining treatments (Torke 2008), as is his professional guardian’s relative preference for care escalation (Cohen 2019). Substituted judgment is the gold standard for making decisions for patients without DMC when values are known; the best interests standard is used when values are unknown - often the case for professional guardians who are strangers to the patient (Jaworska 2017). Conflicts can arise when a patient assigned a professional guardian retains DMC for some decisions, as evidenced here. Quality communication is key when working with professional guardians, as disagreements can lead to patient suffering (Hastings 2014).

Conclusions: C-L psychiatrists play a vital role for patients with professional guardians by assessing DMC and helping advocate for their patients’ wishes when DMC is present.

References:

Cohen, A.B., Benjamin, A.Z., Fried, T.R. End-of-Life Decision-Making and Treatment for Patients with Professional Guardians. J. Am. Geriatr. Soc., 2019, 67: 2161.

Hastings, K.B. Hardships of End-of-Life Care With Court-Appointed Guardians. Am. J. Hosp. Palliat. Med., 2014, 31: 57–60.

Jaworska, A. Advance Directives and Substitute Decision-Making, https://plato.stanford.edu/entries/advance-directives/.

Torke, A.M., Alexander, G.C., Lantos, J. Substituted Judgment: The Limitations of Autonomy in Surrogate Decision Making. J. Gen. Intern. Med., 2008, 23: 1514.