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CASE 26.1

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A 54-year-old married female, Charlene, has insulin-dependent diabetes and has seen you for her care for the last 7 years. In the last year, she has developed diabetic retinopathy and neuropathy. To your great frustration, Charlene continues to resist the recommended lifestyle changes required to control her diabetes.

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She is a casual, friendly woman known as the "candy lady" in her neighborhood where she lives with her husband of 30 years. She loves children and volunteers at the local elementary school, where she is well known for a quick smile, a reassuring hug, and a piece of candy in her large, full pockets. In fact, she is noted during most of her appointments to be munching on M&M's—her favorite candy. She has had dietary consults and many education-oriented doctor appointments but says, "I know I shouldn't eat the way I do, but I just don't have the heart to change who I am, even if it does help my eyes and legs. Who I am is about what I eat and do."

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You wonder about Charlene's capacity for decision-making, given her frank noncompliance with care, even in the setting of serious complications from her diabetes.

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Question 26.1.1 All of the following variables are necessary in decision-making capacity (DMC) EXCEPT:

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A) Ability to communicate a choice.

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B) Voluntary choice.

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C) Understanding of the variables involved in the decision.

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D) Ability to appreciate the personal impact of choices.

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E) Family agreement that the patient is competent.

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Answer 26.1.1 The correct answer is "E." All of the other options are considered important for determining DMC. Certainly family concerns need to be addressed but family agreement has nothing to do with determining a patient's competence. One additional necessary element for DMC is the ability to reason about the options in the setting of personal values.

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Question 26.1.2 What is the most relevant piece of information in Charlene's account that suggests that her capacity is intact?

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A) Therapeutic alliance with you despite noncompliance with treatment recommendations.

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B) Integration into community relationships, including a stable marriage and responsibilities in the elementary school.

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C) Expression of placing perceived self-identity as a higher priority than control of diabetes and its complications.

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D) Awareness that her dietary choices are associated with symptoms of eye disease and neuropathy.

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E) Flagrant disregard for medical recommendations by eating candy while at her appointment.

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