last authored: Dec 2011, David LaPierre
last reviewed:
The unprecedented growth in the number of seniors means there is an increasing need to assess competency.
There is a tough balance weighing the person's autonomy against the need to act in that person's best interests. In general, the rights of the individual supercede the rights of society to interfere.
The is very important, as being found incapable removes a person's rights.
Competence is the ability to make a decision and the minimal conitive capacity required to perform a recognized act. It is a legal judgment located on a continuum, falling into three main categories:
Capacity is a legal, not medical, term. Being capable carries rights. We do not link capacity to test result (ie MMSE) or diagnoses (ie stroke). It is a decision test, related to the environmental context. It is a functional test to see if the individual can meet demands placed on them.
Capacity to consent/refuse treatment, to undertake contractual oblighations, drive, vote, decide lifestyle, testamentary capacity, and participate in research.
Guiding Principles include autonomy vs paternalism, benovlence vs malificence, futility, and resource allocation.
Capacity has nothing to do with the rightness or wrongness of a decision; rather, it only speaks to the quality of thinking. There are two key questions: Does the patient understand the challenges of an issue? and Does the patient appreciate the consequences?
Personal care is the ability to take care of oneself: provide shelter, food, clothing, a safe, secure environment, and manage ADLs. It also includes health.
It is important to assess:
Financial capacity is the ability to administer an estate: manage property, enter contract, make a will, be a corporate partner, act as a trustee, and assign power of attorney.
It is important to assess:
consent to treatment
sign out AMA
Treatment decision competency
Does the patient understand:
Understanding (being able to repeat and explain) and appreciating (being able demonstrate knowledge of consequences) are the key things we look for in competency assessment. A home visit is ideal, but it is not possible, it is critical to bringing someone along to give collateral.
In many places, any physician can legally assess competency. The best folks include family doctors, psychiatrists, and geriatricians. Others can include neuropsychologists, social work, RNs, OT/PT, or other team members.
If competence fluctuates, ensure people are safe during the poorest level of functioning.
Assess for delusions/hallucinations, or any other medical conditions, that would impair competency.
Can people express a choice? Look for:
Can people understand relevant information for decision-making?
Can people appreciate consequences or reasoning?
Standardized assessment and criteria is the goal.
Mental status exam: orientation, memory, concentration, calculations, delusions/hallucinations, insight and judgment, intellect Aid to Capacity Evaluation |
Cognitive assessment tools can provide information about diagnosis, but this has no impact on competnecy. Tools include:
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The substitution decision maker (SDM) makes a decision in relation to a specific medical treatment, if the patient is deemed incapable. This is in accordance with the patient's prior capable informed/expressed wishes, or in according with what the SDM believes to be the patient's best interests. It has nothing to do with what the SDM wants for the patient.
There is a hierarchy determining who is considered the SDM. In Ontario, for example, the hierarchy is:
Psychiatrists must assess capacity to consent to treatment or financial competence in a psychiatric facility, but not personal care competence.
Incompetence can be declared without a judge, and lasts for the duration of hospitalization only
Requires medical evidence from one medical practitioner. Judge must declare a person incompetent, and then appoint a guardian for estate and person.
Adult Protection Act
Sessums LL, Zembrzuska H, Jackson JL. 2011. Does this patient have medical decision-making capacity? JAMA. 306(4):420-7.