Nine conceptual elements for conducting a capacity assessment are: (1) identifying the applicable legal standard(s) (2) identifying and evaluating functional elements constituent to the capacity (3) determining relevant medical and psychiatric diagnoses contributing to incapacity (4) evaluating cognitive functioning The ACE was validated in a large study that showed that a positive evaluation had a likelihood ratio of 8.5 for predicting decision-making incapacity.2,8. "I just want to let things run their natural course." Does this patient have medical decision-making capacity? The test takes 30 to 60 minutes to administer and performs less well in assessing appreciation and reasoning than the MacCAT-T and CCTI.10. Comparison of Competency Evaluation Tools1,2,3,4. 1996;48(2):345–371. The four key components to address in a capacity evaluation include: 1) communicating a choice, 2) understanding, 3) appreciation, and 4) rationalization/reasoning. If the patient is unable to give consent and identifying a surrogate decision maker will result in a delay that might increase the risk of death or serious harm, physicians can provide emergency care without formal consent. The MacArthur Competence Assessment Tools for Treatment (MacCAT-T) is regarded as the gold standard for capacity assessment aids. A 79-year-old male with coronary artery disease, hypertension, non-insulin-dependent mellitus, moderate dementia, and chronic renal insufficiency is admitted after a fall evaluation. Having clearly communicated his choice, you ask the patient if he understands the situation. The MMSE is an attractive alternative because of its widespread use and familiarity; however, it is imprecise with scores from 17 to 23, limiting its applicability. He thinks he is in a clinic and is unable to state the year, but the remainder of the examination is unremarkable. It maintains the roster of designated capacity assessors and responds to … Table 2. J Am Geriatr Soc. J Psychiatr Res. If a formal assessment tool is used, it should be included in the medical record. Berg JW, What do you think will happen to you now? Rather, it uses clinical vignettes to gauge a patient’s ability to make decisions. 11. Berg JW, Patients have medical decision-making capacity if they can demonstrate understanding of the situation, appreciation of the consequences of their decision, and reasoning in their thought process, and if they can communicate their wishes. Following this discussion, you feel comfortable that the patient has capacity to make this decision. Forms and documentation You must clearly document all parts of your capacity assessment and why the patient does not have capacity for the decision in question If you are stopping a patient without capacity from doing things they want to (e.g. Jackson JL. Informed consent involves providing patients with accurate and adequate information about the risks, benefits, and alternatives of a treatment in a manner that is free from coercion. Assessment of patient's competence to consent to treatment. All institutionalized patients lack decision-making capacity. “Mini-mental state”. It is not necessary to perform a formal assessment of capacity on every inpatient. It's important take all practicable steps to help a patient make the decision themselves. 2002. 15. What are the risks of treatment, and what are the odds that you may have a side effect or bad outcome? For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort. Casarett DJ, Hospitalists often care for patients in whom decision-making capacity comes into question. A prototype instrument. 18. Capacity is the ability to make and understand information relevant to a decision, and the ability to appreciate the reasonably foreseeable consequences of a decision (or lack of a decision).1 Generally a person with capacity will be able to: 1. understand the facts of the situation 2. understand the main choices available 3. weigh up those choices, including benefits and risks 4. make and communicate the decision2 5. understand the ramifications of the decision. cases that might involve legal proceedings); and. Previous: Allergy Testing: Common Questions and Answers, Next: Asymptomatic Hyperpigmented Iris Lesion, Home This process can help determine whether the patient demonstrates the four elements of capacity. What is your understanding of your condition? A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. Therefore, if the evaluation indicates that the patient's understanding and rationale are adequate, that generally establishes capacity, even though someone else in the patient's situation might make a different decision.11, Questions to determine the patient's ability to understand treatment and care options. Adapted with permission from Tunzi M. Can the patient decide? He says, "My kidneys are failing. All rights Reserved. Identifying ambulatory cancer patients at risk of impaired capacity to consent to research. Purser KJ, Rosenfeld T. Evaluation of legal capacity by doctors and lawyers: the need for collaborative assessment. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. Several formal assessment tools are available to help with the capacity evaluation. Raba A. A mental capacity assessment is used to assess a person’s mental capacity to cope with stressful situations and determine if the person will be completely capable of performing an assigned task with no damage to his or her psychological state. Harrell LE. Folstein SE, Appelbaum PS. 4. Marson DC, Capacity assessment, the evaluation of the abilities that patients need to be considered competent to make their own health care decisions, thus, has a key role in helping clinicians determine what they should do when patients refuse beneficial treatment. Med J Aust.      Print. According to their strict definitions, lack of competence refers to global decision-making impairment (e.g., finances, property, wills), whereas lack of capacity refers to the inability to make decisions about proposed medical treatments and other aspects of care. Do you trust your doctor? A skillful capacity assessment can also help determine the severity of a patient’s cognitive impairments and improve the effectiveness of conversations with patients and their families. Fracking sites tied to increased heart failure hospitalizations, Calcium burden drives CV risk whether coronary disease is obstructive or not, Medicare finalizes 2021 physician pay rule with E/M changes, CMS launches hospital-at-home program to free up hospital capacity, Primary care journals address systemic racism in medicine, Critical care and COVID-19: Dr. Matt Aldrich, Treatment options for COVID-19: Dr. Annie Luetkemeyer, Managing the COVID-19 isolation floor at UCSF Medical Center, Copyright by Society of Hospital Medicine. Because the four elements of capacity (understanding, appreciation, reasoning, and communication) are built into everyday dialogue and interactions, it can be assumed that patients have the capacity to make medical decisions if their conversation demonstrates basic logic. 2012;60(11):2144–2150. Following the patient’s declaration that dialysis is not something he is interested in, his niece reports that he is a minimalist when it comes to interventions, and that he had similarly refused a cardiac catheterization in the 1990s. The Powers of Attorney Act 2014 says that a person is presumed to have decision making capacity unless there is evidence to the contrary. 2000;48(8):911–918. 1999;14(1):27–34. Specifically, a MMSE >24 has a negative likelihood ratio (LR) of 0.05 for lack of capacity, while a MMSE <16 has a positive LR of 15.5 Scores from 17 to 23 do not correlate well with capacity, and further testing would be necessary. Having documented this discussion, you discharge him to a subacute rehabilitation facility. Karlawish JH, Cary M, Copyright © 2020 American Academy of Family Physicians. If the decision can be delayed until a time when the patient can regain capacity, this should be done in order to maximize the patient’s autonomy.11, Although some question the notion, given our desire to facilitate management beneficial to the patient, the general consensus is that we have a lower threshold for capacity for consent to treatments that are low-risk and high-benefit.12,13 We would then have a somewhat higher threshold for capacity to refuse that same treatment. http://criminal-justice.iresearchnet.com/forensic-psychology/hopkins-competency-assessment-test-hcat, https://www.uml.edu/docs/Mini%20Mental%20State%20Exam_tcm18-169319.pdf, http://www.uniformlaws.org/shared/docs/health%20care%20decisions/uhcda_final_93.pdf, http://www.apa.org/pi/aging/programs/assessment/capacity-psychologist-handbook.pdf, https://www.ethics.va.gov/docs/net/NET_Topic_20021120_Ten_Myths_About_DMC.doc, Allergy Testing: Common Questions and Answers. Copyright © 2018 by the American Academy of Family Physicians. The first step is to ensure that there are no communication barriers impairing the patient's ability to understand information and communicate with the physician. Deciding for others. It is easy to administer, requires no formal training, and is familiar to most hospitalists. PubMed PMID: 25332041. If a patient is found not to have capacity, a surrogate decision maker should be identified and consulted. dialysis, amputation), we have a low capacity to let patients decide for themselves.11,14. On examination, the patient demonstrates disorganized thinking and describes auditory hallucinations. What factors/issues are most important to you in deciding about your treatment? What are you thinking about as you consider your decision? Only psychiatrists and psychologists can assess decision-making capacity. Grisso T. However, a more formal capacity evaluation should … The person’s behaviour or circumstances raise doubt as to whether they have the capacity to … Lack of capacity cannot be demonstrated by referring to a person’s age or appearance, condition or any aspect of their behaviour. He is widowed and lives in an assisted living facility. Capacity is assessed intuitively at every medical encounter and is usually readily apparent. The HCAT is also quick and effective, but it evaluates for generalized incapacity rather than capacity to make specific decisions.13 The HCAT can be helpful if there is concern about the need to transfer decision-making authority to a surrogate, but it is not as helpful if the goal is evaluating for capacity in a specific clinical scenario. “Mini-mental state”. Marson DC, Competence of long-term care residents to participate in decisions about their medical care: a brief, objective assessment. A practical method for grading the cognitive state of patients for the clinician. Adapted with permission from Tunzi M. Can the patient decide? Am Fam Physician. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. It comes with instructions and is specific to each medical decision. Get Permissions, Access the latest issue of American Family Physician. Patients must be able to (1) demonstrate understanding of the benefits and risks of, and the alternatives to, a proposed treatment or intervention (including no treatment); (2) demonstrate appreciation of those benefits, risks, and alternatives; (3) show reasoning in making a decision; and (4) communicate their choice.1,2, Enlarge Equally, deciding that a patient lacks capacity is not an end in itself, and the underlying cause should be addressed. / Vol. Darzins P, If there is no valid medical power of attorney, the closest relative usually becomes the surrogate. Contact These might include physical barriers, such as hearing and vision impairments, dysarthria, or dysphagia.9 Language barriers may also be present, including the use of medical jargon that can confuse patients and cause “pseudo-incapacity.” 2 Jargon and complicated explanations can also cause confusion, but further inquiry and rewording can improve their understanding and allow them to make informed decisions. The Hopemont Capacity Assessment Interview (HCAI) utilizes hypothetical vignettes in a semi-structured interview format to assess understanding, appreciation, choice, and likely reasoning.8,9 Similar to CCTI, HCAI is not modified for individual patients. Competency is a global assessment and a legal determination made by a judge in court. Secker-Einbinder A, Tell me what you really believe about your medical condition. Although capacity usually is defined by state law and varies by jurisdiction, clinicians generally can assume it includes one or more of the four key components: The Mini-Mental Status Examination (MMSE) is a bedside test of a patient’s cognitive function, with scores ranging from 0 to 30.4 Although it wasn’t developed for assessing decision-making capacity, it has been compared with expert evaluation for assessment of capacity; the test performs reasonably well, particularly with high and low scores. Capacity is assessed intuitively at every medical encounter and is usually readily apparent. Etchells E, Darzins P, Silberfeld M, et al. Assessing Health Needs and Capacity of Health Facilities 1 Assessing Health Needs and Capacity of Health Facilities In rural remote settings, the community health “needs” may seem so daunting that it is difficult to know how to proceed and prioritize. Sessums LL, 6. Hospitalists frequently encounter situations in which a patient’s capacity is called into question; in most cases, this is a determination a hospitalist can make independent of consultants. 2004;5(4):263-267. Ten myths about decisionmaking capacity. In cases in which a second opinion is warranted, psychiatry, geriatrics, or ethics consults could be utilized. The reasons for questioning if a person has capacity to make a decision at a particular time may be that: 1. His labs are notable for pot… You have been given a lot of information about your condition. If the patient has an advance directive applicable to the clinical situation, it should be used to guide decisions. Search date: January 2017. Drane JF. Competency is a global assessment and legal determination made by a judge in court. Secker-Einbinder A, That’s how I got the high potassium." 2014 Oct 20;201(8):486-8. The Mini-Mental State Examination (available at https://www.uml.edu/docs/Mini%20Mental%20State%20Exam_tcm18-169319.pdf) and the Montreal Cognitive Assessment (available at http://www.mocatest.org) are two tools that are commonly used to evaluate cognition. et al. Ganzini L, Volicer L, Nelson WA, Fox E, Derse AR. The Mental Capacity Act (MCA) is designed to protect and empower people who may lack the mental capacity to make their own decisions about their care and … His brother reports that the patient has diabetes mellitus and stopped taking his medications six months ago. 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