Bioethics memory aid can help assess patient decision-making capacity in medical emergencies

February 5, 2010

Physicians in training and bioethicists at Johns Hopkins have created an easy-to-remember checklist to help medical students and clinicians quickly assess a patient's decision-making capacity in an emergency.

A report on the acronym CURVES, and how to use it, will be published in the February issue of Chest. CURVES stands for Choose and Communicate, Understand, Reason, Value, Emergency and Surrogate. Doctors and students easily memorize mnemonic devices, and applying this one will help them determine whether a patient is able to make decisions in emergency situations fraught with stress and uncertainty.

The memory aid is designed to uphold the core bioethical principles of patient autonomy and assurance of benefit, says Joseph Carrese, M.D., director of the Program on Ethics in Clinical Practice at the Johns Hopkins Berman Institute of Bioethics.

The gold standard, he said, is to inform the patient about treatment options, make recommendations when appropriate, and have the patient exercise free will in making treatment choices. But in life-or-death situations, because of or the illness itself, determining whether a patient has the capacity to engage in such decision-making can be extremely difficult.

Carrese, a co-author of the paper, said the acronym is easy to learn and should help physicians render a clinical judgment about decision-making capacity during a critical event quicker than with assessment methods used for non-emergency situations. The evaluation device should also help practitioners with documenting emergency-medical decisions.

"If you ask medical students, they can rattle off several dozen mnemonics that they've learned to help remember things and organize their thinking," said Carrese, an associate professor at the Johns Hopkins School of Medicine. "Because it can be remembered and recalled under time pressure, then all the key elements are more likely to be considered and applied."[For instance, one popular medical mnemonic is ABCD, which stands for the various treatment options for a heart attack: aspirin, beta blockers, clot busters and dynamite (nitrates).]

The original idea for CURVES emerged during an educational conference for residents and on clinical ethics led and taught by Carrese. At the conference, Grant Chow, M.D., an internal medicine resident at Johns Hopkins Bayview Medical Center, shared the dilemma he faced with two emergency patients.

Chow then presented the acronym to Carrese, and the two, along with medical student Matthew Czarny and Assistant Professor of Medicine Mark Hughes, M.D., demonstrated the mental checklist in their paper via two challenging scenarios based on the cases Chow shared at the conference.

In the first scenario, an 84-year-old woman with a history of severe, chronic obstructive pulmonary disease is showing symptoms that indicate her condition could soon kill her. She is told that she should be admitted and treated with noninvasive positive pressure ventilation, intubation or comfort care. Instead, she says, "I want to die at home. Please, let me go home."

In the second scenario, a morbidly obese, 53-year-old man is admitted for suspected obesity hypoventilation syndrome and obstructive sleep apnea. At one point, he passes out and stops breathing, but is soon resuscitated. His breathing remains weak, and his head begins to bob. A medical team prepares to intubate him to stabilize his breathing, but the patient blurts out, "I don't want a tube! No tube!"

The checklist reminds practitioners how to quickly assess each patient's decision-making capacity, before acting on their own decision about which treatment option is in their patients' best interests:

C - Can the patient freely choose from among the different treatment options? Are they also able to communicate their preference, either verbally, in writing or through the use of signals? (The authors acknowledge that some persuasion by a physician might be appropriate here.)

U - Does the patient understand the risks, benefits, alternatives and consequences of the various courses of action?

R - Can the patient reason and provide adequate explanation for accepting or declining each intervention?

V - Is the patient's decision consistent with his or her value system?
If the answers to any of those questions are no, or are unclear, Carrese said it is highly unlikely that a patient has adequate decision-making capacity. The doctor can then act on his or her own clinical judgment after confirming two last criteria, which, according to CURVES, are:

E - Is it a true emergency, with serious or imminent risk to life or limb? If so, then decisions need to be made quickly.

S - Is there a surrogate decision-maker or legal document immediately available that details the patient's wishes? If there isn't, and if there is no time for an ethics consultation, then it's up to the doctor.

Following the CURVES process, the physicians let the elderly woman go home. The second patient was intubated.

Carrese cautions that CURVES doesn't diminish the role of clinical judgment. "The mnemonic will help you remember that you have to consider whether the patient is communicating their choice," he said. "But it won't tell you whether they're doing it to an acceptable degree, or adequately."

More information: Program on Ethics in Clinical Practice: www.bioethicsinstitute.org/web … level/2/interior.asp

Related Stories

Recommended for you

Pickled in 'cognac', Chopin's heart gives up its secrets

November 26, 2017
The heart of Frederic Chopin, among the world's most cherished musical virtuosos, may finally have given up the cause of his untimely death.

Sugar industry withheld evidence of sucrose's health effects nearly 50 years ago

November 21, 2017
A U.S. sugar industry trade group appears to have pulled the plug on a study that was producing animal evidence linking sucrose to disease nearly 50 years ago, researchers argue in a paper publishing on November 21 in the ...

Female researchers pay more attention to sex and gender in medicine

November 7, 2017
When women participate in a medical research paper, that research is more likely to take into account the differences between the way men and women react to diseases and treatments, according to a new study by Stanford researchers.

Drug therapy from lethal bacteria could reduce kidney transplant rejection

August 3, 2017
An experimental treatment derived from a potentially deadly microorganism may provide lifesaving help for kidney transplant patients, according to an international study led by investigators at Cedars-Sinai.

Exploring the potential of human echolocation

June 25, 2017
People who are visually impaired will often use a cane to feel out their surroundings. With training and practice, people can learn to use the pitch, loudness and timbre of echoes from the cane or other sounds to navigate ...

Team eradicates hepatitis C in 10 patients following lifesaving transplants from infected donors

April 30, 2017
Ten patients at Penn Medicine have been cured of the Hepatitis C virus (HCV) following lifesaving kidney transplants from deceased donors who were infected with the disease. The findings point to new strategies for increasing ...

0 comments

Please sign in to add a comment. Registration is free, and takes less than a minute. Read more

Click here to reset your password.
Sign in to get notified via email when new comments are made.