Patient Care

How Do I Determine if My Patient has Decision-Making Capacity?

KEY POINTS

  • Competency is a global assessment and legal determination made by a judge in court. Capacity is a functional assessment and a clinical determination about a specific decision that can be made by any clinician familiar with a patient’s case.
  • 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.
  • The four key components to address in a capacity evaluation include: 1) communicating a choice, 2) understanding, 3) appreciation, and 4) rationalization/reasoning.

ADDITIONAL READING

  • Appelbaum PS, Grisso T. Assessing patients’ capacities to consent to treatment. N Engl J Med. 1988;319(25):1635-1638.
  • Ganzini L, Volicer L, Nelson WA, Fox E, Derse AR. Ten myths about decisionmaking capacity. J Am Med Dir Assoc. 2004;5(4):263-267.
  • Appelbaum PS. Clinical practice. Assessment of patients’ competence to consent to treatment. N Engl J Med. 2007;357(18):1834-1840.

Case

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. He is widowed and lives in an assisted living facility. He’s accompanied by his niece, is alert, and oriented to person. He thinks he is in a clinic and is unable to state the year, but the remainder of the examination is unremarkable. His labs are notable for potassium of 6.3 mmol/L, BUN of 78 mg/dL, and Cr of 3.7 mg/dL. The niece reports that the patient is not fond of medical care, thus the most recent labs are from two years ago (and indicate a BUN of 39 and Cr of 2.8, with an upward trend over the past decade). You discuss possible long-term need for dialysis with the patient and niece, and the patient clearly states “no.” However, he also states that it is 1988. How do you determine if he has the capacity to make decisions?

Overview

Hospitalists are familiar with the doctrine of informed consent—describing a disease, treatment options, associated risks and benefits, potential for complications, and alternatives, including no treatment. Not only must the patient be informed, and the decision free from any coercion, but the patient also must have capacity to make the decision.

Hospitalists often care for patients in whom decision-making capacity comes into question. This includes populations with depression, psychosis, dementia, stroke, severe personality disorders, developmental delay, comatose patients, as well as those with impaired attentional capacity (e.g. acute pain) or general debility (e.g. metastatic cancer).1,2

ave for the comatose patient, whether the patient has capacity might not be obvious. However, addressing the components of capacity (communication, understanding, appreciation, and rationalization) by using a validated clinical tool, such as the MacCAT-T, or more simply by systematically applying those four components to the clinical scenario under consideration, hospitalists can make this determination.

Table 1. Ten Myths About Capacity

  1. Decision-making capacity = competency.
  2. Against medical advice = lack of decision-making capacity.
  3. There’s no need to assess decision-making capacity unless a patient goes against medical advice.
  4. Decision-making capacity is all or nothing.
  5. Cognitive impairment = no decision- making capacity.
  6. Lack of decision-making capacity is permanent.
  7. Patients who have not been given relevant information about their condition can lack decision-making capacity.
  8. All patients with certain psychiatric disorders lack decision-making capacity.
  9. All institutionalized patients lack decision-making capacity.
  10. Only psychiatrists and psychologists can assess decision-making capacity.

Source: Ganzini L, Volicer L, Nelson WA, Fox E, Derse AR. Ten myths about decisionmaking capacity. J Am Med Dir Assoc. 2004;5(4):263-267.

Review of the Literature

It is important to differentiate capacity from competency. Competency is a global assessment and a legal determination made by a judge in court. Capacity, on the other hand, is a functional assessment regarding a particular decision. Capacity is not static, and it can be performed by any clinician familiar with the patient. A hospitalist often is well positioned to make a capacity determination given established rapport with the patient and familiarity with the details of the case.

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