At the 2002 convocation on ethics, CICSW student Geoffrey Shaskan presented a paper on some of the crucial issues facing health care professionals when obtaining voluntary consent for the elderly. The following is an excerpt from his presentation, including his original protocols for assessment of patients when there is a need for voluntary consent to treatment or admission to a hospital.

---

It is my strong conviction that each health facility should devise and follow a standardized, reliable protocol for determining competence to consent to psychiatric hospitalization. When doubt about competence arises, there should be multiple assessors and evaluations by family, friends, clergy, and Health Care Providers (HCP).

An important consideration is the site of evaluation. "There is some evidence that in-home assessment may reveal the optimal cognitive function of geriatric patients" (Kapp, 1992, p.124).

Another particularly problematic issue is that of persuasion of the patient to agree to the hospitalization. "If the HCP staff considers the medical intervention to be both necessary and proper for a particular patient, they are not only authorized but obligated to use maximum persuasive powers, short of coercion, to influence the patient to reverse field" (p. 207). Families and others may also be useful in persuading the patient to follow a prescribed course.

I have devised a system for assessment of voluntary admission using the concepts of "adequate," "marginal," and "inadequate," in which each patient is viewed through the lens of "degree" of mentation. For example, to know his name and that he is in or willing to go to a hospital, the patient must be able to manage, albeit simply, the capacities to receive information, recognize at some level that he needs the hospital, and to remember this to the extent that he does not say to the HCP, for example, "I want to return to the nursing home."

There are times when the HCP uses the family’s persuasive powers along with his own influence to help the patient make an important decision and to think about the alternatives that would face him if he did not choose to become a voluntary patient. By default, the patient is ranking the alternatives. When it comes to selecting an option, the HCP can be helpful to the patient and to the family by providing as much information as possible regarding the hospitalization. The patient must then be willing to sign or place a mark on the Voluntary Consent Form and in so doing makes the choice for admission. Some basic considerations apply: patients must know their name, know that they are in the hospital, and be willing to stay.

The five steps in the assessment of voluntary admission are:

Each patient is then evaluated in light of the following capacities: the ability to1) receive information, 2) recognize relevant information, 3) remember relevant information, 4) relate situations to oneself, 5) reason about alternatives, and 6) rank alternatives.

I have been able to devise a system whereby a health care facility treating the elderly can make decisions regarding voluntary treatment. By no means have I taken subjectivity out of the process of decision–making, but have maintained the standard of "full disclosure to the patient" regarding treatment and its alternatives. It is essential to involve a team that includes the patient, the family, the health care providers, and other people from the patient's social network. By rating capacities as marginal and inadequate, I have addressed the ethical questions that may be raised regarding voluntary admission. Whenever concerns about the consequences for the health and safety of the patient are raised, I discuss my findings and review my thinking with my colleagues.

Bibliography

Kapp, Marshall B. (1992). Geriatrics and the Law: Patient’s Rights and Professional Responsibilities. New York: Springer.

---

Geoffrey Shasken, M.S.W., a student at CICSW, is Director of Social Services for Santa Rosa Memorial Hospital In-patient Psychiatric Services and is in private practice in San Francisco.

back to top