Executive Summary
Clinicians from Johns Hopkins University School of Medicine have developed a mnemonic-driven tool to help clinicians quickly assess whether patients have decision-making capacity during emergency situations. The approach uses the mnemonic "CURVES" to guide physicians to first consider whether patients have decision-making capacity, and then to determine whether treatment can be commenced without informed consent.
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The first four letters of the mnemonic "CURVES" stand for: choose and communicate, understanding, reason, and value. The authors note that these four qualities/abilities need to be present to establish decision-making capacity.
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The last two letters of the pneumonic stand for emergency and surrogate, prompting physicians to consider whether the patient is at imminent risk and whether there is a surrogate decision-maker available.
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The authors note that while the issues represented by the CURVES pneumonic should be very familiar to clinicians, effective use of the tool requires training and practice.
Emergency providers need to make quick decisions when patients are brought into the ED with life-threatening conditions, and, of course, these decisions need to be consistent with the patient's wishes. However, what does the provider do if he or she has an inkling that a patient's decision-making capacity may be compromised?
It's a challenging circumstance and it is also quite common, according to Joseph Carrese, MD, MPH, a professor in the Department of Medicine at the Johns Hopkins University School of Medicine, and a core faculty member at the Johns Hopkins Berman Institute of Bioethics in Baltimore, MD. "These can be high-stakes situations," he says. "There is a continuum of seriousness, but certainly in a country where we are having an epidemic of older patients with dementia and Alzheimer's disease, for example, these issues come up very frequently, and physicians need to know how to deal with them."
To date, there hasn't been much in the way of practical guidance to help physicians quickly assess the decision-making capacity of patients in emergency situations, but Carrese and three co-authors, led by Grant Chow, MD, chief electrophysiology fellow at the Heart and Vascular Institute at Johns Hopkins University School of Medicine in Baltimore, MD, have developed an approach that they believe can help to fill this void.1
Focus on key considerations
At the heart of their approach is the mnemonic "CURVES", which is designed to cue physicians to the key considerations medical experts and ethicists say are important in determining decision-making capacity:
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The "C" stands for choose and communicate, prompting the provider to assess whether the patient can make and communicate a choice without coercion.
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The "U" in the mnemonic represents understanding, prompting the provider to consider whether the patient understands the risks and benefits of his or her choice as well as any alternative choices and the consequences involved.
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The "R" stands for reason, signaling that the provider needs to assess whether the patient is able to reason. This should prompt the provider to ask the patient to explain logically why he or she made the particular decision or choice.
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The "V" stands for value, and should cue a provider to think about whether the patient's choice is consistent with his or her values. Physicians need to make every effort to understand the patient's values as well as the reality that values and goals can change.
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The "E" stands for emergency. This should prompt the provider to consider whether there is an imminent risk to the patient.
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The "S" stands for surrogate, cueing the provider to assess whether a surrogate decision-maker is available.
The authors note that the first four letters in the mnemonic (CURV) represent steps that can help providers determine whether a patient has decision-making capacity, while the last two (ES) represent important considerations about whether emergency treatment can be delivered without informed consent.
Establish structure, document steps
The "CURVES" tool was drawn from the literature regarding decision-making capacity, but also relies heavily on the Ethics Manual of the American College of Physicians, explains Chow. "What we really wished to do with this was to quickly summarize what someone can do in a five-minute encounter, if we are forced into that sort of situation, to try our best to determine the best course of action in an emergency," he says.
In fact, what prompted Chow to delve into this issue was his own personal experience with difficult cases in which he struggled to ascertain whether he should provide life-saving treatment to patients who stated that they did not want the treatment, but it wasn't clear whether they had the appropriate mental capacity or stability in their current state to make such decisions. "I had no easy way of determining [decision-making capacity] in an expedited fashion," he explains. "That was one of the big challenges when we were in an ICU setting."
Chow adds that it is not unusual for clinicians to get the sense that a patient does not or may not understand what they are saying. "That person has to be able to reasonably give you a belief as a physician that they are able to do these four things [represented by the first four letters in the mnemonic]," he says. "Otherwise, it just doesn't sit right with you, and sometimes I think as a provider you just don't understand yourself why the decision a person just gave you doesn't sit with you quite right."
Effective implementation of the "CURVES" tool takes time, acknowledges Chow. "With any protocolized decision-making assistance tool like this, it takes practice. It is just like running a code," he says. "You need to look at it ahead of time, and it is one of those things, just like a code algorithm, that you need to keep right at the tip of your brain for when the situation arises."
However, Carrese notes that issues raised by the "CURVES" tool are hardly unfamiliar to medical students or practicing clinicians. "Communicating with patients, patients making choices, and patients understanding what they are talking about - physicians get exposure to [those issues] throughout medical school and residency training, so they will be familiar with these domains and how to go about assessing them," he says. "What they will be less familiar with is how these are packaged in a way that will help them [achieve] the clinical skill of assessing decision-making capacity, so I think that is really where the challenge comes in training."
Chow observes that while the issues represented by the mnemonic may not be new to clinicians, the tool can help them organize things in their minds so that they don't miss an important step when they encounter a patient in an emergency situation. "It can also help you document what you have done which helps to keep things safe and in a very stepwise fashion," he says.
Continue the discussion
There are no plans to put the CURVES tool through any kind of rigorous testing, but Carrese observes that the tool has prompted further discussion and debate about the issues involved, and some clinicians have embraced it. "People are using this, other papers have cited it in the literature, and when I go to ethics meetings, people come up to me and say they are using it when they are teaching," he explains. "Clinical educators who are interested in bioethics are teaching medical students or residents to use this as a way to succinctly convey information about assessing decision-making capacity to those learners."
Chow adds that he, too, has received positive feedback about the approach. "It just seems to me that [people] are happy to have a structured way of approaching these problems, "he says. "If you don't have a structured way, sometimes it can be very daunting for somebody in training."
Chow also notes that some groups have amended the mnemonic by adding a couple of letters to it. "I think that speaks to how many people are interested in it and how many people do wish for something like this to be widely available," he says. "Hopefully we will be able to come to a consensus as to what is the best way of figuring out what somebody would want in an emergency - and how we can determine that quickly."
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Chow G, et al. CURVES: A mnemonic for determining medical decision-making capacity and providing emergency treatment in the acute setting. Chest 2010;137:421-427.
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Joseph Carrese, MD, MPH, Professor, Department of Medicine, Johns Hopkins School of Medicine, and Core Faculty Member, Johns Hopkins Berman Institute of Bioethics, Baltimore, MD. E-mail: [email protected].
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Grant Chow, MD, Chief Electrophysiology Fellow, Heart and Vascular Institute, Johns Hopkins University School of Medicine, Baltimore, MD. E-mail: [email protected].
