It is not unusual to hear about the use of a leading question (where the answer is implied in the question) as a physician or nurse or family member attempts to get an advance directive regarding “do not resusitate” or “no intubation” statement or some other treatment decision from a sick hospitalized patient. The leading question may come in the form of “You don’t want to be intubated and suffer the discomfort, do you?” or “You don’t want them to pull the plug”, “You want everything done, don’t you?” Often there might not be a whole lot more of an explanation to a patient who is more concerned at the moment with the discomfort and suffering of the illness or who is in a somewhat mentally obtunded state. Use of these questions, in this way or even if given as a direct question such as “Do you want everything done?” is hardly the way to ask a sick patient to make a decision. It really comes down to “what is everything?”, “what is going to be done and how effective will it be to achieve the goals of the patient?” “What does pulling the plug actually mean? Is it to terminate unwanted treatment that is keeping the patient alive or is also to terminate needed comfort care?” Unfortunately when these decisions are left to the last minute, there doesn’t seem to be enough time, enough knowledge or just plain not enough understanding about how to communicate to be certain that the patient’s answer is what the patient really wants. And if answers to these questions are acted on as valid, well.. someone is fooling themselves.
These questions which may be requesting life and death decisions on the part of the patient deserve first a careful evaluation of the patient’s mental capacity to make medical decisions. Secondly it requires the questioner to provide some reasonable detail of the clinical situation so that the patient can make an informed decision. And finally, questions should be presented to the patient in non-coercive ways with the absence of leading questions. Leading questions are acceptable in the courtroom but never in medical communication. I want to emphasize that the proper communication with the patient should apply not only to the healthcare workers but also to family members who quiz the patient about their wishes.
As I have noted above, the first duty of anyone trying to obtain a medical decision from a patient is to verify that the patient has the mental capacity to form that decision for themselves. This is best determined by the patient’s physician. It is usually not necessary to request a psychiatric consultation to make the determination. The method is relatively simple. The patient should be alert, oriented and able to communicate. The patient should be able to demonstrate at least good short-term memory so that when information is presented or questions asked by the examiner, the patient will be able to recollect at the time of making a decision. The next step is to test the patient’s judgment. “You find an envelope on the sidewalk which has an address printed on it and bears an uncancelled stamp, what should you do?” What would you do? The examiner knows the correct answer, does the patient? If the patient passes this far, the next steps would deal with the clinical situation. I would suggest the following questions to see if the patient understands the significance of a personal medical decision. The examiner might not use these exact words but the request should be used in these contexts: 1) “Tell me what you know about your illness, treatment, result of treatment or no treatment” 2) Then instruct the patient regarding the illness, treatment and the result of treatment or no treatment.
3) Now discover whether the patient has learned from the examiner’s explanations. “Can you tell me what you now understand about your illness, treatment, result of treatment or no treatment?” 4) “What is your hope, goal or wish?” 5) “What would you want to be done about your illness?” 6) “Tell me why you decided as you did.” Notice that none of the questions are leading questions and the question 5 which requests a decision is open-ended in that it doesn’t give any hints of what could or could not be decided. From the answers to these questions and particularly question 6, the examiner might sense some significant depression. In this event, consultation with a psychiatrist might be helpful.
All of the above discourse is my own personal opinion and my way of thinking of how to make for a medical decision by the patient that one can feel confident that it will represent a truly autonomous and informed decision and that one has confidence that acting on it will be fair and ethical. I would appreciate reading any visitors views of this important part of medical care based on their own past experience. ..Maurice.
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