Understanding
Capacity to understand the medical situation and treatment alternatives
Reasoning
Capacity to reason and provide rational reasons for and against different treatment choices
Appreciation
Capacity to appreciate the personal consequences associated with a particular treatment choice
Choice
Capacity simply to make a choice (yes or no) about a particular medical treatment
Table 38.2
Research consent abilities
Understanding | Capacity to understand the nature of the research study and research questions and procedures |
Reasoning | Capacity to reason about and provide rational reasons for and against participation in a research study |
Appreciation | Capacity to appreciate the personal risks and benefits associated with participation in a research study |
Choice | Capacity simply to make a choice (yes or no) about participation in a research study |
Financial capacity
This capacity refers to a person’s ability to perform financial tasks and make financial decisions in a manner that meets a person’s needs and that is consistent with the person’s values and self/best-interest [11, 13]. Financial capacity involves a broad range of conceptual, procedural, and judgmental skills [14] ranging from simple skills such as counting coins/currency to more complex skills such as using a checkbook and register, paying bills, and making investment decisions [13, 14].
From a clinical standpoint, financial capacity comprises both performance abilities , and also judgment skills supporting financial decisions that promote and protect the individual’s best interests. Financial capacity has been clinically conceptualized using a three-tier model that comprises [4, 14]:
specific financial abilities or tasks
broader domains of financial activities relevant to independent living
overall or global financial capacity
The model’s financial tasks and domains are presented in Table 38.3.
Table 38.3
Clinical conceptual model of financial capacity
Domains | Tasks |
|---|---|
Basic monetary skills | •Naming coins/currency |
•Understanding coin/currency relationships | |
•Counting coins/currency | |
Financial conceptual knowledge | •Defining financial concepts |
•Applying financial concepts | |
Cash transactions | •Grocery purchases |
•Calculating change/vending machine | |
•Calculating a tip | |
Checkbook management | •Understanding a checkbook |
•Using a checkbook/register | |
Bank statement management | •Understanding a bank statement |
•Using a bank statement | |
Financial judgment | •Detecting mail fraud risk |
•Detecting telephone fraud risk | |
Bill payment | •Understanding bills |
•Prioritizing bills | |
•Preparing bills for mailing | |
Knowledge of personal assets/estate arrangements | •Knowing personal asset ownership and estate arrangements |
Investment decision-making | •Understanding investment options, returns on investment choices, risks of investments |
In evaluating financial capacity, it is important to determine at the outset what have been the individual’s premorbid levels of financial knowledge and experience. This will allow the clinician to make informed judgments as to how specific financial skills may have been affected by neurological and other injuries, and to ensure that lack of premorbid financial experience is not confused with the effects of injury [14].
Importance
Although the topic of capacity has received a fair amount of attention in the psychiatric and dementia literature [4, 8, 10, 12, 15], a much smaller body of literature exists in the rehabilitation setting [16, 17]. As reflected below, the rehabilitation literature on capacity can be divided into conceptual and empirical studies.
- A.
Conceptual Literature/Findings
This literature has focused primarily on issues of decision-making capacity in TBI patients, and has highlighted the following points:
Cognitive and emotional sequelae of brain injury can directly impact an individual’s decisional capacity [18].
Acutely brain-injured patients in rehabilitation settings often face complex medical decisions such as shunting, orthopedic surgery, rehabilitation programming, and neuropsychiatric treatment [16, 19, 20].
During rehabilitation and recovery, decisions will need to be made regarding the TBI patient’s capacity to consent to medical treatments, to manage financial affairs, and to consent to research [21].
The nature, recovery, and sequelae of brain injury poses different capacity issues for healthcare providers working in the rehabilitation setting [21, 22].
Due to the high prevalence of cognitive impairment, the rehabilitation patient population is considered to be vulnerable, and special research safeguards need to be in place to ensure adequate protection of these individuals when consenting to research studies [22].
- B.
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Empirical Literature/Findings
Over the past 10 years , a small body of empirical capacity research has emerged examining issues of treatment consent capacity and financial capacity in patients with TBI. In addition, very recent studies have examined TCC and RCC in patients with brain cancer. Key findings from these empirical studies are presented below:
- 1.
Treatment Consent Capacity in TBI
The level of initial capacity impairment and rate of recovery depends in part on the severity of the brain injury. Key findings from the studies examining TCC in TBI populations are summarized below.
- a.
Cross-Sectional Studies . Using the Capacity to Consent to Treatment Instrument (CCTI), cross-sectional studies have investigated TCC in individuals with acute TBI (1-month post-injury) across a range of injury severity [16, 19, 23] (see Section on Selected Capacity Assessment Instruments below for a description of the CCTI.).
Mild TBI
Complicated Mild TBI
Compared to controls, patients with complicated mild TBI performed worse on the understanding standard [23].
No statistically significant differences between mild and complicated mild TBI groups although larger samples are needed to detect this difference.
Capacity impairment occurred in 50 % of persons with complicated mild TBI [19].
- b.
Longitudinal Studies. Two studies have investigated recovery of TCC over a 6-month recovery period after TBI in a group of patients with a range of injury severity [16, 23]. Both studies used the CCTI to assess TCC.
Mild TBI
At 6 months, the mild TBI group performed equivalently with controls and complicated mild TBI patients on all TCC standards [23].
Relative to controls, at 6 months post-injury, 20 % of mild TBI patients had impaired performance on the CCTI.
Complicated Mild TBI
At 6 months, the complicated mild TBI group performed equivalently with controls on all consent standards [23].
A third of complicated mild TBI patients demonstrated TCC impairments at 6 months post-injury.
Moderate to Severe TBI
At 6 months after TBI, the moderate to severe TBI group demonstrated significant improvements on all of the consent standards, but continued to demonstrate impairment on the appreciation and understanding standards compared to controls [23].
About half of moderate to severe TBI patients demonstrate impairment on one of the CCTI standards at 6 months.
- a.
- 2.
Neurocognitive Predictors of TCC in TBI
Neurocognitive predictors of TCC have been examined in patients with mild TBI (uncomplicated and complicated mild cases) and with moderate to severe TBI [17, 24].
Mild TBI
Higher academic achievement as measured by the Wechsler Adult Intelligence Scale-3rd edition (WAIS-III) Arithmetic subtest [25] and the Wide Range Achievement Test-3rd edition (WRAT-3) Reading test [26] composite score predicted higher appreciation scores.
Higher verbal memory predicted higher reasoning and understanding scores.
Moderate to Severe TBI
Verbal fluency and academic achievement predicted appreciation.
Academic achievement predicted reasoning and understanding. Verbal memory also predicted under-standing.
At 6-month follow-up, executive function, verbal processing speed, and working memory predicted performance on understanding (S5); working memory and short-term memory predicted reasoning (S4); and basic executive functioning predicted appreciation (S3) [17].
- 3.
Financial Capacity in Moderate to Severe TBIRelated posts:
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