Competency
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Introduction
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.
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:
Levels of assessment
Urgent: life threatening injury
Non-urgent, clear cut: ie obvious dementia
Non-urgent, complex: ie early dementia. Assessment from other relevant health care professionals. Few consults, more time.
- personal care
- financial capacity
- medical care
Personal care
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:
- Appreciation of strengths and weaknessess, and willingness to make use of supports if necessary.
- History of poor judgment resulting in harm to self or others.
Financial capacity
Financial capacity is the ability to administer an estate: manage property, enter contract, make a wil, be a corporate partner, act as a trustee, and assign power of attorney.
It is important to assess:
- Assess assets, income, expenses, and debt. Get corroboration by collateral. Get a history of past management of finances in the past.
- If poor judgement is used, what are the implications?
- Patient's preference for estate management.
- Will they accept a financial advisor?
Medical care
consent to treatment
sign out AMA
Treatment decision competency
Does the patient understand:
- the condition for which the treatment is proposed?
- the nature and purpose of the treatment?
- risks in undergoing, or not undergoing, treatment
Assessing Competency
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, geriatricians, 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:
- expressive aphasia: look for nonverbal techniques
- poor memory - inability to make a consistent choice
- depression and attending ambivalence
Can people understand relevant information for decision-making?
- impaired coprehension: receptive aphasia, poor attention span, psychiatric concerns (delusions or denial)
Can people appreciate consequences or reasoning?
- depression - delusions of punishment or hopelessness
- frontal lobe damage - evaluating consequences, insight into significant of problems, mental flexibility to adapt to changes
When Not to Assess
Is formal assessment necessary?
15% of referrals are dismissed, due to the motive not being in the best interests of the patient, a misunderstanding of the legal consequences, or another
Assessment Tools
Standardized assessment and criteria is the goal.
mental status exam: orientation, memory, concentration, calculations, delusions/hallucinations, insight and judgment, intellect
cognitive assessment:
- Montreal Cognitive Assessment
- clock drawing
- F words/animals in 60 seconds
- similarities
- trails B: good planning/organizing test
- frontal assessment battery
What We can Do
It is good to take dangerous things away, bit by bit.
Substitute Decision Makers
Re: medical decisions, there is a hierarchy
- person authorized under a Medical Consent Act
- court-appointed guardian
- spouse or common-law partner
- adult child
- parent
- adult sibling
- any other adult next of kin
- public trustee
SDMs make a decision in relation to a specific medical treatment, 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.
Acts
Hosptials Act
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
Incompetent Person's Act
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
Resources and References
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