POLST Signature Requirements: Responding With Compassion While Ensuring Informed Consent
Research Article
Robert Macauley, Susan Tolle
American Journal of Hospice and Palliative Medicine, 1 September 2020
Open Access
Abstract
The majority of states require the signature of a surrogate decision maker on a POLST form for a patient who lacks decisional capacity. While commendable in its intention to ensure informed consent, in some cases this may lead the surrogate to feel that they are signing their loved one’s “death warrant,” adding to their emotional and spiritual distress. In this paper we argue that such a signature should be recommended rather than required, as it is neither a sufficient nor necessary condition of informed consent. Additional steps—such as requiring the attestation and documentation of the signing health care professional that verbal consent was fully informed and voluntary—can achieve the ultimate goal of respecting patient autonomy without adding to the surrogate’s burden.

Who Has the Ability to Consent?
Downey VA, Zun L
The Primary Care Companion for CNS Disorders, 19 August 2020; 22(4)
Abstract
Objective
Previous studies have shown no consistent examinations for testing the ability of patients to consent in hospital emergency departments (EDs). The primary objective of this study was to compare providers’ opinions with 3 capacity assessment tools to determine the ability of medical and psychiatric patients to consent in the ED.
Method
The study was conducted at a level 1 inner-city general hospital ED from June 2016 to October 2017. The study participants comprised a random sample of English-speaking patients aged ≥ 18 years who presented with any medical or psychiatric complaint. Each patient was administered 3 tools: the standard ED consent form, the Aid to Capacity Evaluation (ACE), and the Mini-Mental State Examination. The results of these assessments were then compared to the provider’s opinion of the patient’s ability to provide consent.
Results
A total of 283 patients participated in the study, and 84.4% were able to consent according to providers. There was a high level of consistency with the provider’s assessment and the other assessment tools on the patient’s ability to consent. Most patients, both medical and psychiatric, showed the ability to consent. However, this was less true for psychiatric patients with schizophrenia, as 32.6% (n = 14) were unable to consent.
Conclusions
The study revealed that the ACE capacity assessment was highly consistent with the providers’ assessment for medical (88.3%) and psychiatric patients (80.3%), but not for psychiatric patients with schizophrenia. Using the ACE, patients with schizophrenia presenting to the ED were significantly less able to understand their illnesses (0.01) and treatments (0.04) and thus were less able to give consent.

Investigating assumptions of vulnerability: A case study of the exclusion of psychiatric inpatients as participants in genetic research in low‐ and middle‐income contexts
Andrea C. Palk, Mary Bitta, Eunice Kamaara, Dan J. Stein, Ilina Singh
Bioethics, 14 January 2020
Abstract
Psychiatric genetic research investigates the genetic basis of psychiatric disorders with the aim of more effectively understanding, treating, or, ultimately, preventing such disorders. Given the challenges of recruiting research participants into such studies, the potential for long‐term benefits of such research, and seemingly minimal risk, a strong claim could be made that all non‐acute psychiatric inpatients, including forensic and involuntary patients, should be included in such research, provided they have capacity to consent. There are tensions, however, regarding the ethics of recruiting psychiatric inpatients into such studies. In this paper our intention is to elucidate the source of these tensions from the perspective of research ethics committee interests and decision‐making. We begin by defining inpatient status and outline some of the assumptions surrounding the structures of inpatient care. We then introduce contemporary conceptions of vulnerability, including Florencia Luna’s account of vulnerability which we use as a framework for our analysis. While psychiatric inpatients could be subject to consent‐related vulnerabilities, we suggest that a particular kind of exploitation‐related vulnerability comes to the fore in the context of our case study. Moreover, a subset of these ethical concerns takes on particular weight in the context of genetic research in low‐ and middle‐income countries. At the same time, the automatic exclusion of inpatients from research elicits justice‐related vulnerabilities.

Prevalence of the Inability to Give Informed Consent in the Elderly Orthopaedic Trauma Population [DISSERTATION]
David G. Clossey
Harvard Medical School Doctoral Dissertation, 2020
Abstract
Purpose
Despite the fact that fractures are a leading cause of morbidity in the elderly, a study of the prevalence of the inability to give informed consent in the elderly orthopaedic trauma population has, to the best of our knowledge, not been performed. In addition, the condition of mild cognitive impairment (MCI) has become increasingly recognized since the introduction of the Montreal Cognitive Assessment (MoCA). By simultaneously determining capacity for consent (by clinician gestalt – the gold standard) and degree of cognitive impairment (by utilizing the MoCA), we hope to better understand the relationship between the ability to consent and MCI as well as the specific components of cognition that may allow for decision-making capacity (DMC).
Methods
This prospective study was carried out at Brigham and Women’s Hospital (BWH). English and Spanish speaking patients older than 65 who were admitted for orthopaedic injury requiring surgical management were included in the study. Those who had previously known dementia and delirium were excluded from the study, as well as those who were unable to communicate. (NB: A recent IRB amendment has now allowed us going forward to approach certain patients with known dementia and delirium). Attending physicians determined whether or not a patient had DMC. Independently, a research staff member administered the confusion assessment method (CAM) short form to screen for delirium and the MoCA to screen for cognitive impairment. Various other background data were obtained retrospectively.
Results
While the prevalence of the inability to give informed consent cannot be determined since the project is still actively recruiting patients, we hypothesize that this prevalence is at least 15.6%. While patients with DMC had various demographic data characteristic of the elderly orthopaedic trauma population, 81.8% had an abnormal total MoCA score. Participants generally scored worse on tasks assessing for certain cognitive domains, such as visuospatial/executive function tasks (mean score: 46.7%) and the delayed recall task (mean score: 40%). The vast majority of participants (90.5%) who struggled with the delayed recall task were, however, able to remember additional words with category and/or multiple choice clues. None of the participants had a positive screen for delirium.
Conclusions
Mild cognitive impairment at the time of consent appears not to preclude a patient from having DMC. Although the relationship between cognitive ability and DMC remains not well understood, further conclusions regarding early cases of dementia should be studied going forward. Deficits in certain domains of cognitive thinking may be correlated with an inability to give informed consent, although a comparison of testing results between patients with versus without DMC will be required to further understand this idea.