1 In a patient with subtle symptoms or signs of cognitive decline (e.g., family concerns, medication errors, repetitive questions, decline in personal hygiene),
- Initiate assessment of mental competency, including use of a standardized tool,
- Refer for further assessment when necessary.
How to Assess Capacity
DIRECTED CLINICAL INTERVIEW
- Questions to determine the ability of the patient to understand about treatment and the proposed options for care
- What is your understanding of your condition?
- What are the options for your situation?
- What is your understanding of the benefits of treatment and what are the odds that the treatment will work for you?
- What are the risks of treatment and what are the odds that you may have a side effect or bad outcome?
- What is your understanding of what will happen if nothing is done?
- Questions to determine the ability of the patient to appreciate how that information applies to their own situation:
- Tell me what you really believe about your medical condition.
- Why do you think your doctor has recommended (name of specific treatment or test) for you?
- Do you think it (specific treatment/test) is the best treatment/test for you? Why or why not?
- What do you think will actually happen to you if you accept this treatment? If you don’t accept it?
- Questions to determine the ability of the patient to reason with that information in a manner that is supported by the facts and the patient’s own values
- What factors/issues are most important to you in deciding about your treatment? What are you thinking about as you consider your decision?
- How are you balancing the pluses and minuses of the treatments?
- Do you trust your doctor? Why or why not?
- What do you think will happen to you now?
- Questions to determine the ability of the patient to communicate and express a choice clearly:
- You have been given a lot of information about your condition. Have you decided what medical option is best for you right now?
- We have discussed several choices; what do you want to do?
FORMAL ASSESSMENT TOOLS
1. Aid to Capacity Evaluation (ACE) – ACE
- Domains 1-4 evaluate whether the person understands his or her current medical problems, the proposed treatment and other options (including withholding or withdrawing treatment).
- Domains 5 and 6 evaluate whether the person appreciates the consequences of their decision (see sample questions above).
- For domain 7, if the person appears depressed or psychotic, then decide if the decision is being affected by the depression or psychosis.
- For domain 7a, if the person appears depressed, determine if the decision is affected by depression. Look for the cognitive signs of depression such as hopelessness, worthlessness, guilt and punishment.
- For domain 7b, if the person may be psychotic, determine if the decision is affected by delusion/psychosis.
- Pt are presumed capable, for the overall impression, if uncertain, then err on the side of calling a person capable.
2. The MacArthur Competence Assessment Tool (MacCAT)
- lengthy, comprehensive tool designed for patients with complex psychiatric or neurologic conditions whose capacity determination is especially difficult
2 In a patient with a diagnosis that may predict cognitive impairment, (e.g., dementia, recent stroke, severe mental illness) identify those who require more careful assessment of decision-making capability.
Assess a patient’s decision-making capacity more carefully than usual when:
- Pt have an abrupt change in mental status 2º to:
- hypoxia, infection, medication, metabolic disturbances,
- an acute neurologic or psychiatric process, or other medical problem
- Pt refuse recommended treatment, especially
- when they are not willing to discuss the refusal
- when the reasons for the refusal are not clear
- when the refusal is based on misinformation or irrational biases
- Pt consent to particularly risky or invasive treatment too hastily and without careful consideration of the risks and benefits.
- Pt have a known risk factor for impaired decision-making:
- A chronic neurologic or psychiatric condition
- A significant cultural or language barrier
- An education level concern
- An acknowledged fear or discomfort with institutional health care settings
- At an age at either end of the adult spectrum (< 18 yo or > 85 yo)
3 When a patient is making decisions (e.g., surgery/no surgery, resuscitation status) think about the need to assess their mental competency.
Perform a mental status examination (along with a physical examination and laboratory evaluation, if needed), 4 specific abilities should be assessed:
- the ability to understand information about treatment
- the ability to appreciate how that information applies to their situation
- the ability to reason with that information
- the ability to make a choice and express it.
4 In a patient with cognitive impairment, identify intact decision-making abilities, as many may be retained.
The lack of any one ability does not mean that a patient lacks the overall ability to make a decision.
- Eg. patients with limited education, with diverse cultural backgrounds or with minimal prior experience in a medical setting may not completely understand all the alternatives to, or all the major risks of, a proposed treatment. However, they may still have enough understanding overall to make their own decisions.
If the patient lacks the capacity for decisionmaking, a determination of surrogacy will be necessary. In the best-case scenario, the patient may have previously appointed an agent; in the worst-case scenario, the court may need to become involved. (The discussion of surrogacy is too broad for this article, but it has been well-covered elsewhere.). If the patient does not have an advance directive or health care proxy, the surrogate will need to make decisions based on principles of “substituted judgment”(what the patient would have decided) or “best interest” (what the surrogate judges to be best for the patient).