Innovations In Clinical Neuroscience

MAR-APR 2017

A peer-reviewed, evidence-based journal for clinicians in the field of neuroscience

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Innovations in CLINICAL NEUROSCIENCE [ V O L U M E 1 4 , N U M B E R 3 – 4 , M A R C H – A P R I L 2 0 1 7 ] 42 R I S K M A N A G E M E N T • Determine the patient's ability to apply given information regarding his or her own medical situation • Determine the ability of the patient to reason with the information in a manner supported by the facts and the patient's own values • Determine the patient's ability to communicate and express a choice clearly. 2 If you determine that your patient is unable to provide consent to his or her treatment, then you must look to a surrogate decision-maker. In many instances, this person will be someone who has been appointed as the legal guardian of the patient or is someone who holds a power of attorney for healthcare decisions. If either of these is the case, the person claiming the right to make medical decisions should have legal documents granting such authority. You should request copies of these documents and also consider enlisting the assistance of your risk manager or attorney to determine the holder's right to consent to treatment. Oftentimes, those holding a power of attorney will have only been granted the right to make financial decisions for the patient. If formal arrangements have not previously been made, then family members may be entitled to make decisions on behalf of the patient. As laws may vary from state to state, you should familiarize yourself with your state's laws concerning substituted consent. In some instances you may wish to discuss with patients the use of a Psychiatric Advance Directive (PAD), which are essentially advance directives planned for mental health decisions. PADs are gaining in popularity and psychiatrists can expect to see more of their use in the future. PADs may be used to name a healthcare proxy or may give specific instructions regarding the type of care a patient wishes to receive (or not receive) in the event of a psychiatric crisis. Psychiatric advocacy groups such as National Alliance on Mental Illness (NAMI) and Mental Health America support the use of PADS as a way to promote patient autonomy. The National Resource Center on Psychiatric Advance Directives is an excellent resource for finding state-specific information on the use of PADS. 3 Recognize that therapeutic interventions require special attention to ensure the safety of elderly patients. PRMS Inc. claims data reflect that most lawsuits against psychiatrists include allegations involving medications. Careful medication management is particularly crucial when dealing with elderly patients who may have declining mental capacity and other co-occurring somatic conditions. The following is a list of suggestions for reducing risk and increasing patient safety when prescribing for elderly patients: Before prescribing • Understand and be knowledgeable about current intervention techniques and professional standards/guidelines regarding the treatment of elderly patients. One example of this is, the American Psychiatric Association (APA) Practice Guidelines on the Use of Antipsychotics in Patients with Dementia. 4 • Make certain that you are aware of all medications your patient is currently taking. Ask the patient to bring in all medications he or she is currently taking each time the patient visits your office. This should also include over-the-counter medications and supplements. • Remember to consult your state's prescription monitoring program (PMP) —even if you are not technically required to check it. Elderly patients may not always accurately report all of their medications. • Communicate with other treatment providers about the important aspects of the patient's treatment— especially medications. Elderly patients are more likely to have co- occurring somatic conditions. Medications used for the treatment of those conditions can interact with other medications and place the patient at risk of serious injury. • Be aware of the increased risk of injury from falls, to which elderly patients may be especially vulnerable when benzodiazepines and other sedating or performance-inhibiting medications are prescribed. Performance-inhibiting medications call for careful monitoring. • Discuss with your patient the risks of the medications being prescribed, including risk of falls and driving impairment. After prescribing • Provide patients with written instructions on how and when to take medications. Make certain that you use clear, concise language and explain the purpose of each medication and its intended effect. Alert patients to dangerous side- effects. • To the extent possible, simplify dosing regimens and encourage the use of devices, such as pill dispensers with reminder alarms or smartphone pill reminder apps, to aid patients in taking their medication. • Encourage patients to fill prescriptions at only one location. • Be aware of the increased risk of over- and under-medicating elderly patients. Monitoring patients for the continued effectiveness and safety of prescribed medications is crucial. • Suggest to your patients that they write down any problems or concerns they are having regarding their medication so that they can be discussed during your next

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