Competency

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:

Can people understand relevant information for decision-making?

Can people appreciate consequences or reasoning?

 

 

 

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:

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

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