A consensus-based approach to providing palliative care to patients who lack decision-making capacity

Making palliative care decisions for a patient who lacks decision-making ca pacity presents several challenges. Other people, such as family and caregi vers, must choose for the patient. The goals and values of these decision m akers may conflict with those of each other and with those of the patient, who now lacks the capacity to participate in the decision. This paper prese nts a case study of a patient with severe Alzheimer disease who has two com mon clinical problems: neurogenic dysphagia and aspiration pneumonia. The c ase study describes a consensus-based decision-making strategy that keeps w hat is known about the patient's wishes and values in the foreground but al so expects guidance from the physician and elicits input from family member s and other people who care for and have knowledge about the patient. The s teps of this process, including key clinical prompts and potential transiti on statements, are outlined and described. The overall goal of the case com mentary is to demonstrate that physicians can guide a highly emotional and personal process in a structured manner that has meaning for the patient, f amily, physician, and other caregivers.