I’m incorrigible; I’m trying to use WordPress Presentation Shortcode again to make a short presentation on decisional capacity assessment. This is a frequent request, I mean to help with decisional capacity assessment, not shortcode, of course.
This by no means does much more than scratch the surface of this issue, but it’s what’s essential for trainees to know when they rotate through the psychiatry consultation service.
What a lot of non-psychiatric clinicians don’t know is that they’re often the ones in the best position to assess the decisional capacity of their patients. Psychiatrists are helpful when there’s a neuropsychiatric syndrome present which we can evaluate to see if it’s substantially interfering with decision-making.
As always with this presentation shortcode thingy, you have to use the arrow keys to navigate each and every line on the slides. If you want to see the slideshow in full screen, click the 4 arrrow icon in the lower right hand corner. Hit ESC to exit full screen.
This slideshow could not be started. Try refreshing the page or viewing it in another browser.
Just What the Heck is Decisional Capacity Anyway?
- Often psychiatrists asked to evaluate “competency”–which courts establish
- Psychiatric consultants can’t decide competency per se, but can help by assessing decisional capacity
- Capacities are time and task specific, meaning the best bet is to help the consultee focus on what exactly the issue is, e.g., leaving the hospital against medical advice, refusing a diagnostic or therapeutic procedure, etc.
- Importantly, on many occasions, the problem isn’t so much a need to assess decisional capacity–but to help figure out where the communication breakdown occurred between doctor and patient
Core Abilities Related to Capacity
- Ability to
- Express a choice
- Understand relevant information
- Appreciate significance of information for one’s own situation and the consequences of decisions
- Reason through treatment options or weigh the pros and cons
- Frequently, the assessment is best carried out tag-team style with both consultee and consultant in the room talking with (not at) the patient
- Consultee often in best position to explain risks and benefits of procedures
- Consultant can be most effective assessing whether mental disorder substantially interferes with decision-making
When is the Best Time to Assess Capacity?
- Abrupt change in mental status, often signals delirium
- Refusal of recommended treatment, especially when
- Unwilling to discuss reasons for the refusal
- Based on misunderstanding or apparent irrationality
- Overly hasty consent to risky treatments
- Presence of known risk factors for impaired decision-making
- Chronic neuropsychiatric disorder, e.g., dementia; however, the mere diagnosis of psychiatric disorder doesn’t necessarily imply inability to make medical decisions
- Cultural, language barrier
- Lower academic achievement; age extremes
Questions to Ask the Patient
- What do you understand about your illness?
- What can you tell me about the risks and benefits of what your doctor wants to do for you?
- What would happen if nothing were done for you?
- What do you really believe about your condition?
- Why do you think the intervention is best for you now (or why not)?
- How do you weigh the pros and cons of the treatment choices?
- Expression of choice
- We’ve talked about your choices; what would you prefer to do?
The Sliding Scale Model for Assessing Capacity Thresholds
- When the risk is favorable and the patient consents or if unfavorable and refuses
- Generally the lower the expectation for capacity
- When the risk is favorable and the patient refuses or unfavorable and consents
- Generally have higher expectation for capacity
- So if risk to your reputation is low for taking a picture of you with the Bronze Fonz–go ahead, we don’t expect that much from you
Pitfalls of Casting the Psychiatrist as “Informed Consent Technician”
- Incapacity is presumed; psych is expected to remove legal barriers to getting surrogate decision-maker’s consent
- Consultee expects psych to persuade patient to consent to treatment
- Psych expected to provide documentation that will protect against potential litigation
- Corollary occurs when psych requests “medical clearance” for certain psych treatments
- Best solution is to collaborate in the humanistic assessment of the patient, i.e., team-based model
Capacity Assessment Reviewed
- Determine if the patient can understand, appreciate, reason, and make a voluntary choice without undue influence from others, including medical professionals
- View capacity assessment as a process
- Treat impediments to understanding, etc., and reassess in the setting of treatable conditions like delirium
- Consider getting other disciplines involved if available: neuropsychology, spiritual services, occupational therapy
- Clearly document the process
A Few Words About Decisional Capacity Rating Scales
- Aid to Capacity Evaluation
- Developed at University Toronto Center for Bioethics
- Brief 95-10)
- Useful to organize process but still requires assessor judgment
- MacArthur Competence Assessment Tool (MacCAT)
- Based on Grisso and Appelbaum book, Assessing competence to consent to treatment, Oxford Univ Press, 1998
- Lengthy (30 min)
- Still need assessor judgment and there’s a fee for use charge
Resources and References
- Zaubler, T. S., M. Viederman, et al. (1996). “Ethical, legal, and psychiatric issues in capacity, competency, and informed consent: an annotated bibliography.” General Hospital Psychiatry 18(3): 155-172.
- Ganzini, L., L. Volicer, et al. (2003). “Pitfalls in assessment of decision-making capacity.” Psychosomatics 44(3): 237-243.
- Tunzi, M. (2001). “Can the patient decide? Evaluating patient capacity in practice.” American family physician 64(2): 299-306.
- Jones, R. C. and T. Holden (2004). “A guide to assessing decision-making capacity.” Cleveland Clinic journal of medicine 71(12): 971-975.
- The Practical Psychosomaticist: James Amos, M.D.
- More Help with Decisional Capacity Assessments | The Practical Psychosomaticist: James Amos, M.D.
- Decisional Capacity Assessment in a Podcast from POGOe! | The Practical Psychosomaticist: James Amos, M.D.
- Are Psychiatrists the Only Doctors Who Can Assess Decision-Making Capacity? | The Practical Psychosomaticist: James Amos, M.D.
- Competency or Capacity and Who Does What? | The Practical Psychosomaticist: James Amos, M.D.