Clinical and ethical implications of impaired executive control functions for patient autonomy

The authors identify the clinical and ethical implications of impaired executive control functions for patient autonomy. Executive control functions are processes that orchestrate relatively simple ideas, movements, or actions into complex goal-directed behavior, and impairments in these functions are becoming more common as the population ages. The authors examine difficulties that individuals with impaired executive control functions may have in making treatment decisions and describe a practical, ethically justified framework for making treatment decisions for patients with impairments in these functions. Three components of autonomy are identified-intentionality, understanding, and voluntariness. Intentionality and voluntariness are especially affected by impaired executive control functions. Impairments of these aspects of autonomy may often be overlooked when only traditional mental status examinations are employed, with adverse consequences for the health of patients wrongly thought to possess intact ability to make and carry out plans of care. Two case vignettes illustrate the complexities faced by clinicians intervening with patients who have deficits in decision-making capacity caused by impaired executive control functions.