When to assess capacity

Abrupt change in mental status

Refusal of recommended treatment

Not willing to discuss refusal

Reasons for refusal not clear

Refusal based on misinformation or irrational biases

Hastily consenting to risky or invasive treatment without careful consideration of risks or benefits

Known risk factor for impaired decision making

Chronic neurologic or psychiatric condition

Significant cultural or language barrier

Educational level

Acknowledged fear or discomfort with institutional health care settings

Adolescents younger than 18 years or adults older than 85 years

How to assess capacity

Components

When consulted:

Confirm that informed consent was attempted and patient given adequate information

Request for capacity is task specific

Directed clinical interview (see below)

Collateral from other clinicians and caregivers

Screening for depression and/or suicidality

Screening for psychosis

Screening for altered mental status/delirium

Physical assessment

Laboratory evaluation and studies, particularly to rule out reversible causes of altered mental status

Screening for cognitive impairment

Mini-mental state exam (MMSE)

Directed clinical interview

1.

Determine ability of patient to understand treatment and proposed care options and how they apply this information to their own situation

Understanding of their condition

What specific test or treatment has their doctor recommended

Whether they think the specific test or treatment is best for them and reasons for and against

Understanding of the benefits of treatment and what are the odds that the treatment will work for them

Understanding of the risks of treatment and what are the odds that they may have a side effect or bad outcome

Understanding of outcome if nothing done

Understanding of outcome if treatment accepted

Understanding of any alternatives to proposed treatment

2.

Determine ability of patient to reason with above information in a manner that is supported by the facts and the patient’s own values

What factors/issues are important to patient in deciding about their treatment

Does patient trust doctor? Why or why not?

3.

Determine ability of patient to communicate and express a choice clearly

Formal assessment tools

Aid to Capacity Evaluation (ACE)

MacArthur Competence Assessment Tool (MacCAT)

Who should assess capacity?

Primary care physicians are qualified to perform capacity assessments

Psychiatry consultation

Patients lacking capacity

When appropriate, intervention to restore reversible causes of lack of capacity, such as altered mental status/delirium, acute psychiatric illness

A determination of whether surrogacy will be necessary

Bioethics panel and/or risk management for complicated cases