Patient Classification -- more uncertainities

To illuminate problems in making decisions about the care of the elderly the Office of Technology Assessment (OTA) devised a classification system consisting of four categories of "physical status" and four categories of "decisionmaking capacity." Most of these categories are not articulated in practice, but they influence a person's ability to make treatment decisions for himself or herself and may also influence the decisions made by others on a person's behalf.

Variation in Physical Status
A life-threatening condition may be--and in elderly persons frequently is--superimposed on preexisting physical and/or mental disorders, or it may occur in an otherwise healthy and active individual. Unfortunately, some medical providers lump together all elderly persons who become candidates for life-sustaining technologies, but every elderly person should be seen as individuals with widely varying physical and mental status. Physical conditions may be acute or chronic, have different prognoses (both of survival and restoration of functional ability), and have a course that is either decisive or unknown. The four categories of "physical status" are:

1. Severely debilitated
   
2. Chronically ill
   
3. Critically ill
   
4. Terminally ill

Chronically ill -- persons have one or more chronic conditions that may or may not be life-threatening but that reduce chances of recovery and restoration of function in the event of and acute disease. Included in this group are persons who have a life-threatening chronic condition that has been stabilized, with or without a life-sustaining technology, or that is in remission (e.g., chronic renal failure treated with dialysis; cancer in remission). Many chronic conditions that are not immediately life-threatening are mildly or severely debilitating; some (e.g., hypertension) increase the risk of acute life-threatening illnesses or the risk of complications associated with acute disease.

Critically ill -- persons are those in the midst of an acute life-threatening episode (e.g., cardiac arrest, stroke) or persons believed to be in imminent danger of such and episode. They are medically unstable, and if they are not treated, are expected to decline.

Terminally ill -- individuals are those for whom a prognosis of death has been made. Designation as terminally ill usually requires diagnosis of an illness that has a predictable fatal progression that cannot be stopped by any known treatment. A widely accepted definition of "terminal illness" includes the expectation that death will occur within 6 months. This definition has been adopted by Medicare. In practice, however, accurate prognosis is extremely difficult, and this difficulty adds to the dilemmas regarding treatment decisions. Contrary to popular belief, a terminal illness is not always identifiable as such, and most patients who are dying have not been declared as "terminally ill." Only retrospectively can these designations be reliably made.

Variations in Decisionmaking Capacity
Again, to illuminate problems in making decisions about healthcare, the OTA devised four categories regarding the decisionmaking capacity of an individual with respect to his or her medical treatment. However, these are theoretical categories as OTA points out and any one category is not an absolute for any one individual. Like the physical status, a person's decisionmaking capacity may be different from time to time and may be expected to improve or worsen. The four categories are:

1. Individuals may be capable of making decisions about their medical care (and all other aspects of their life), and their decisionmaking capacity may be assumed to be stable.

2. Individuals may be currently capable of making decisions about their medical care, but this status is assumed to be unstable or declining. Persons whose lucidity fluctuates and those with progressive dementing disorders are examples.

3. Individuals may be currently incapable of making decisions, but it is expected that their decisionmaking capacity will be restored. This category includes patients who are unconscious, severely depressed or confused due to reversible causes (e.g., anesthesia, drug toxicity, pain).

4. Individuals may be permanently incapable of making decisions about their medical care (and everything else). In these persons, there is no sign of ability to absorb and evaluate information or to express a preference, and there is no realistic prospect of change. Examples include patients in a persistent noncognitive state, irreversible coma, and persons who are severely demented.

The combination of the patient's physical and mental status may affect both the decisionmaking process and the decision that is reached. For example, in some States, a patient's request for nontreatment is granted only if the patient is deemed both decisionally capable and terminally ill. Or, a critically ill patient, regardless of decisionmaking capacity, might be excluded from the decisionmaking process because of the need for immediate action.