February 5, 2010
Learning ‘Curves':Bioethics Memory Aid Can Help Assess Patient Decision-Making Capacity In Medical Emergencies
Physicians in training and bioethicists at Johns Hopkins have created an easy-to-remember checklist to help medical students and clinicians quickly assess a patient's decision-making capacity in an emergency.
A report on the acronym CURVES, and how to use it, will be published in the February issue of CHEST. CURVES stands for Choose and Communicate, Understand, Reason, Value, Emergency and Surrogate. Doctors and students easily memorize mnemonic devices, and applying this one will help them determine whether a patient is able to make decisions in emergency situations fraught with stress and uncertainty.The memory aid is designed to uphold the core bioethical principles of patient autonomy and assurance of benefit, says Joseph Carrese, M.D., director of the Program on Ethics in Clinical Practice at the Johns Hopkins Berman Institute of Bioethics.
The gold standard, he said, is to inform the patient about treatment options, make recommendations when appropriate, and have the patient exercise free will in making treatment choices. But in life-or-death situations, because of severe pain or the illness itself, determining whether a patient has the capacity to engage in such decision-making can be extremely difficult.
Carrese, a co-author of the paper, said the acronym is easy to learn and should help physicians render a clinical judgment about decision-making capacity during a critical event quicker than with assessment methods used for non-emergency situations. The evaluation device should also help practitioners with documenting emergency-medical decisions.
"If you ask medical students, they can rattle off several dozen mnemonics that they've learned to help remember things and organize their thinking," said Carrese, an associate professor at the Johns Hopkins School of Medicine. "Because it can be remembered and recalled under time pressure, then all the key elements are more likely to be considered and applied."[For instance, one popular medical mnemonic is ABCD, which stands for the various treatment options for a heart attack: aspirin, beta blockers, clot busters and dynamite (nitrates).]
The original idea for CURVES emerged during an educational conference for residents and medical students on clinical ethics led and taught by Carrese. At the conference, Grant Chow, M.D., an internal medicine resident at Johns Hopkins Bayview Medical Center, shared the dilemma he faced with two emergency patients.
Chow then presented the acronym to Carrese, and the two, along with medical student Matthew Czarny and Assistant Professor of Medicine Mark Hughes, M.D., demonstrated the mental checklist in their paper via two challenging scenarios based on the cases Chow shared at the conference.
In the first scenario, an 84-year-old woman with a history of severe, chronic obstructive pulmonary disease is showing symptoms that indicate her condition could soon kill her. She is told that she should be admitted and treated with noninvasive positive pressure ventilation, intubation or comfort care. Instead, she says, "I want to die at home. Please, let me go home."
In the second scenario, a morbidly obese, 53-year-old man is admitted for suspected obesity hypoventilation syndrome and obstructive sleep apnea. At one point, he passes out and stops breathing, but is soon resuscitated. His breathing remains weak, and his head begins to bob. A medical team prepares to intubate him to stabilize his breathing, but the patient blurts out, "I don't want a tube! No tube!"
The checklist reminds practitioners how to quickly assess each patient's decision-making capacity, before acting on their own decision about which treatment option is in their patients' best interests:
C "“ Can the patient freely choose from among the different treatment options? Are they also able to communicate their preference, either verbally, in writing or through the use of signals? (The authors acknowledge that some persuasion by a physician might be appropriate here.)
U "“ Does the patient understand the risks, benefits, alternatives and consequences of the various courses of action?
R "“ Can the patient reason and provide adequate explanation for accepting or declining each intervention?
V "“ Is the patient's decision consistent with his or her value system?
If the answers to any of those questions are no, or are unclear, Carrese said it is highly unlikely that a patient has adequate decision-making capacity. The doctor can then act on his or her own clinical judgment after confirming two last criteria, which, according to CURVES, are:
E "“ Is it a true emergency, with serious or imminent risk to life or limb? If so, then decisions need to be made quickly.
S "“ Is there a surrogate decision-maker or legal document immediately available that details the patient's wishes? If there isn't, and if there is no time for an ethics consultation, then it's up to the doctor.
Following the CURVES process, the physicians let the elderly woman go home. The second patient was intubated.
Carrese cautions that CURVES doesn't diminish the role of clinical judgment. "The mnemonic will help you remember that you have to consider whether the patient is communicating their choice," he said. "But it won't tell you whether they're doing it to an acceptable degree, or adequately."
The work was funded by the Morton K. and Jane Blaustein Foundation, and by the office of Ronald Peterson, president of Johns Hopkins Health System and executive vice president of Johns Hopkins Medicine.
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