Decision Making Capacity

 ·   ·  ,

In the 1914 case of Schloendorff versus the Society of New York Hospital, Justice Cardozo wrote, “every human being of adult years and sound mind has a right to determine what shall be done with his own body.” Determining a "sound mind," or decision making capacity is something that we do often in the emergency department. This makes many providers uncomfortable because it gives patients the ability to refuse our recommendations. This POTD is going to go over what defines capacity and how we can assess it. 

Capacity refers to the ability of a person to utilize information about their illness and proposed treatments to make a choice that aligns with their values. Determining capacity is often a clinical judgment typically made by a physician, whereas competence is a legal state determined by a judge. Assessing for capacity allows us to act in our patient’s best interest while respecting their autonomy. 

You can assess for capacity by determining if the patient has the ability to: 1. Communicate 2. Understand the information 3. Understand the situation 4. Manipulate the information presented and make a logical decision.

These points can be ascertained by asking the patient to recount their story, your recommendations, state what they do or don't want, and back their decision up with logic. 

It is important to note that capacity is defined around a specific medical decision; you should assess capacity with each new intervention or treatment proposed. In addition, capacity can be transient and exist along a continuum. So before you call up psych to help determine if your patient can refuse dialysis, go through these 4 points and see if you can determine decision making capacity yourself.

Thanks for reading!

Ariella

References: 

https://www.emrap.org/episode/november2014/decisionmaking

https://www.uptodate.com/contents/assessment-of-decision-making-capacity-in-adults

Ariella Cohen

M.D. Emergency Medicine

Maimonides Medical Center

Why is dialysis free?

 ·   ·  ,

Today, I’ll be touching on kidney failure and the reimbursement structure in the United States. As we all know, there’s been decades of debate regarding universal healthcare in the US. However, dialysis is different – lucky for you, your kidneys are completely covered under Medicare.

What part of kidney disease is covered under Medicare?

In 1972, President Nixon and Congress signed a bill ensuring free dialysis and renal transplants for US citizens. On average, Medicare covers 80% of dialysis costs. Medicare covers most of the costs for kidney transplants, and Medicare B covers 80% of immunosuppressant medication costs.

Quick stats:

  • Roughly 750,000 people in the US have kidney failure. 

  • ~550K patients get dialysis each year, and the numbers each year keep rising.

  • ~200K patients have kidney transplants in the US.

  • Over 100,000 patients are on the kidney transplant list. ~20-22K patients get kidney transplants each year.

What’s the cost to Medicare?

On average, each dialysis patient costs Medicare about $90,000/year. This totals $28 billion/ year, and composes roughly 7% of Medicare spending. 

The racial disparities:

African Americans represent 35% of dialysis patients, despite making up only 13% of the US population. Hispanics/Latinos, Native Americans, and Pacific Islanders are also much more likely to have kidney disease.

Types of dialysis:

There are two types of dialysis: hemodialysis and peritoneal dialysis. About 90% of US patients get hemodialysis in the US.

~12% of ESRD patients receive HD at home in the US, while the remainder receive it at dialysis centers. Not all countries work like this. Some countries favor peritoneal dialysis at home. For reference, over 80% of ESRD patients get peritoneal dialysis at home in Hong Kong.

The controversies:

I’m not going into the controversies too much about in-center dialysis. You can quickly Google it, or ask John Oliver about it. Just a few things to note: the US has some of the highest mortality rates for ESRD patients in the world, despite the highest spending. Shocking, I know. There are some theories about this: 

  • Per federal guidelines, a doctor does not need to present at the HD center. 

  • Only one nurse must be present at the facility. Many for-profit dialysis centers have minimal staffing.

  • Quick patient turnover leading to poor sanitation practices and higher infection rates.

Morbidity & mortality:

Not surprisingly, kidney failure portends a bad prognosis. There’s a 20% mortality rate within 1 year of starting HD, with a large fraction falling into the initial 90 day period. The 5 year survival rate is about 50%. 

On the other hand, kidney transplant receivers have a survival rate > 80% over 5 years.

The 2 most common causes of death for dialysis patients are:

#1 Cardiovascular disease and sudden cardiac death

#2 bacteremia (26x higher risk than the general population)

  • ¾ are from gram+ bacteria. Most commonly from Staph Aureus, MRSA, Staph epidermidis. 

  • Also gram- ¼ of the time: E Coli, Klebsiella.

Tell me more about home hemodialysis?

There are three types of *home* hemodialysis (not peritoneal dialysis.) It takes a bit of legwork for a patient to arrange this, but it is possible.

  1. Conventional home HD: Q2D, 3-4 hours long; just like the center

  2. Short daily home HD: 5-7 times per week, lasting about 2-3 hours

  3. Nocturnal home HD: QD or Q2D, lasting roughly 6-8 hours

****If there is ANYTHING to take away from this post, please remember this:****

Some patients are never informed about kidney transplants. I recommend quickly having a conversation with your dialysis patients to ensure they are educated about it. As you can see from above, there’s a huge survival benefit. Patients have to contact a transplant center to get added to the waitlist: https://optn.transplant.hrsa.gov/about/search-membership/ 

References:

https://www.washingtonpost.com/news/powerpost/paloma/the-health-202/2019/07/11/the-health-202-the-government-funds-kidney-dialysis-for-all-who-need-it-but-the-program-needs-fixing/5d25f517a7a0a47d87c570ac/ 

https://www.kidney.org/atoz/content/homehemo 

https://pharm.ucsf.edu/kidney/need/statistics#:~:text=Hemodialysis%20care%20costs%20the%20Medicare,patient%20care%20is%20%243.4%20billion

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5099594/

Emergency Medicaid

 ·   · 

I wanted to touch on a topic that I’ve always wanted to learn more about: Emergency Medicaid. As ER docs, I think it’s important to know what resources we have available for our patients. 

Some of this varies by state, so I would recommend quickly familiarizing yourself with the state guidelines. The information provided below is specific to New York state. 

What is Emergency Medicaid?

The federal government requires each state to provide Medicaid coverage for the “care and services necessary for the treatment of an emergency medical condition.”


What services are considered “emergency?”

  • “Absence of immediate medical attention could put the patient in serious jeopardy, seriously impair bodily functions, or cause serious dysfunction to an organ or body part.”

  • Cancer treatment: chemotherapy, radiation treatment, prescription medications

  • Emergency surgeries (not elective)

  • Emergency L&D services


So who’s eligible for Emergency Medicaid?

  • Undocumented immigrants may apply for Emergency Medicaid.

  • There are four criteria for Emergency Medicaid eligibility:

  1. The patient is a district resident

  2. The patient has an emergency medical condition

  3. The patient meets income requirements

  4. The patient is not eligible for ongoing Medicaid due to their citizenship or immigration status


For New York Medicaid (not *emergency* Medicaid), here is the criteria for eligibility. As you can see, it doesn’t capture a lot of our patient population. The patient must be:

  • NY resident / US citizen, and

  • Pregnant, or

  • Be responsible for a child </=18 years old, or

  • Blind, or

  • Have a disability or a family member in the household with a disability, or

  • 65+ years old


Some conditions require you to fall below certain income thresholds:

Have a household income (before taxes) that is below 138% of the federal poverty level. For reference, this translates to:

  • 1 member household: <$17,131

  • 2 member household: <$23,169

  • 3 member household: <$29,207

  • 4 member household: <$35,245

How do I help my patient sign up for it?

Our social work and case management teams are very helpful in facilitating this process. https://nystateofhealth.ny.gov/


How long does it last for?

  • If Emergency Medicaid is approved, it will cover future and past costs associated with the medical condition for a maximum of fifteen months.

  • Retroactive coverage maximum: 3 months

  • Prospective coverage maximum: 12 months

  • It can last for up to twelve months or as long as the person is experiencing the emergency, whichever is shorter.

Misc:

  • Emergency Medicaid does not affect someone’s ability to apply for legal status

  • This is not reported to US Immigration & Customs Enforcement.

References: 

http://www.wnylc.com/health/entry/70/
https://www1.nyc.gov/assets/ochia/downloads/pdf/fly-957-emergency-medicaid-english.pdf
https://dhcf.dc.gov/service/emergency-medicaid
https://www.benefits.gov/benefit/1637  https://www.health.ny.gov/health_care/medicaid/emergency_medical_condition_faq.htm