Caring for Patients Whose Decision-Makers Have Questionable Capacity: Ethical and Clinical Concerns (FR459)

•Describe the phenomenon of decision makers with questionable capacity and its ethical implications in adult care.•Explore the ethical implications and obligations associated with care of pediatric patients whose decision makers may lack adequate capacity to make needed decisions.•Discuss strategies for managing situations involving decision makers suspected of being impaired. Palliative care clinicians commonly face high complexity and stressful decision making. Decisions by surrogates occur for 25%-30% of hospitalized adults, and in pediatrics parents usually serve as legal surrogates. The ethical and legal authority for such decisions is well established. However, not well described are problems with decision-makers suspected of impaired decisional capacity. These individuals may have well-recognized or undiagnosed psychiatric disorders, impairment from substance abuse, or cognitive disorders such as dementias. Unfortunately, clinicians caring for the index patient have no standing to formally assess surrogates, to substantiate suspicions that the decision maker are impaired, or to direct them to health care services. In some circumstances, e.g., suspected abuse or neglect of minors or elders, clinicians may have options for reporting surrogates to public authorities. In all cases, clinicians may have ethical obligations to intervene on behalf of dependent, vulnerable patients. Clinicians may also have ethical duties to the impaired decision maker, even without a clinician-patient relationship. How ought clinicians manage these circumstances? In this presentation we discuss these challenges from the perspectives of a pediatric palliative care physician, an adult palliative care physician, and a palliative care social worker.