Capacity, Informed Consent, and Guardianship

Medical decision-making based on informed consent is a fundamental principle of ethical medical practice. When a patient lacks medical decisional capacity and is unable to give truly informed consent, an agent must be sought to act on the behalf of the person. This chapter reviews the principles underlying determination of the capacity to give informed consent regarding healthcare decisions in a clinical setting. Cognitive loss, emotional distress, or disengagement or the perception that the patient is choosing unwisely or as a result of influence may be concerns that lead to consultation. In contrast to the clear standards for medical decision-making capacity, statutory guidance and case law are essentially nonexistent regarding what standard applies to the capacity to create or to change an advance health directive (AHCD) or to change or designate a healthcare agent. In addition to current decision-making capacity, the consultant must address broader issues of functional or management capacity when the patient’s ongoing capacity to manage personal care and health is at issue, as is relevant to the petition for guardianship. A comprehensive forensic geriatric psychiatry consultation will assist with the care of the patient.</p

Hypoglycemia is Associated with Increased Risk for Brain Injury and Adverse Neurodevelopmental Outcome in Neonates at Risk for Encephalopathy

OBJECTIVE: To investigate the contribution of hypoglycemia in the first 24 hours after birth to brain injury in term newborns at risk for neonatal encephalopathy. STUDY DESIGN: A prospective cohort of 94 term neonates born between 1994 and 2010 with early postnatal brain MRI studies were analyzed for regions of brain injury. Neurodevelopmental outcome was assessed at one year of age. RESULTS: Hypoglycemia (glucose <46mg/dL) in the first 24 hours after birth was detected in 16% of the cohort. Adjusting for potential confounders of early perinatal distress and need for resuscitation, neonatal hypoglycemia was associated with a 3.72-fold increased odds of corticospinal tract injury (P=0.047). Hypoglycemia was also associated with 4.82-fold increased odds of one-point worsened neuromotor score (P=0.038) and a 15-point lower cognitive and language score on the Bayley Scales of Infant Development (P=0.015). CONCLUSION: Neonatal hypoglycemia is associated with additional risks in the setting of neonatal encephalopathy with increased corticospinal tract injury and adverse motor and cognitive outcomes