Assessing Medical Decision Making Capacity Marc Zisselman M.D. Sheppard Pratt Health System Director Geriatric Service Line * I have no disclosures, conflicts of Interest relevant to this Presentation
Obtaining Informed Consent Required by law and medical ethics Appropriate information disclosure Balance between autonomy/beneficence
When to Assess Capacity Intrinsic aspect of every physician patient interaction Initiation of treatment Often Suboptimal -modalities to optimize capacity
Capacity and Competency Terms often used interchangeably Legal vs. Clinical judgments Physicians determine capacity, when to seek substituted judgment
How Common is incapacity Medical inpatients Mental illness Intensive care units, nursing homes Neurodegenerative diseases
Commonly Encountered Conditions Alzheimer s Disease Parkinson s Disease Stroke Traumatic rain Injury End of Life
The four Decision Making Abilities that Constitute Capacity Understanding Appreciation Reasoning Expressing a choice
Understanding Grasp fundamental meaning of information Risks/Benefits/Alternatives/Refusal Tell me in your own words.
Appreciation Application of Facts to one s own life Acknowledgement of illness Choices consonant with prior decisions, values, beliefs Finger amputation for pianist vs. psychiatrist questions
Reasoning Manipulate facts and concepts to arrive at logical coherent decision Process by which a decision is reached How did you decide
Communication a Choice Clear and consistent choice Undue influence
Approaches to Assessment Semi-structured Interview Mini Mental State Exam MacArthur Competence Assessment tool for Treatment Assessment of Capacity for Everyday decisions Capacity to treatment Interview Resident Assessment Instrument /Minimum Data set 2.0 * Only Supplement to Clinical Evaluation
The Decision Capacity Gradient Sliding Scale Approach Not all components must carry equal weight Varies directly with seriousness of likely consequence of patients decisions Dimensional
Challenges Refusal of assessment Family disagrees with assessment Consequences of finding incompetence Situational competence in some areas
Advance Healthcare Directive May Contain - living will - power of attorney Only 10-30% of older adults have advanced directives
Progressive Surrogacy Advance directives to decide proxy If none look for family consensus Hierarchy of relatives - spouse - adult child - parents of patient - siblings
Guardianship Assigned by judge Reasons include No healthcare surrogate/next of kin Feuding first degree relatives Next of kin clearly acting in self interest
Family Members Decisions ½ uses substitute judgment ½ best interests
Reasons for not using Substituted Judgment No discussion of healthcare preferences Incorporating quality of life into decision Unrealistic expectations of /for patient Influence of healthcare professionals
Palliative and End of Life Care Right to refuse medical interventions Right to terminate medical interventions - Artificial nutrition and hydration
End of Life Treatment Decisions Age 60 42% require decisions in final days 70% lacked decision making capacity 33% of them lacked advanced directives
Difficult Cases Care providers come to agreement - best interest standard incorporating knowledge of patient Shared understanding of caregiving team critical
Consent for Sex Issues include - voluntariness - recall learning form past experiences
Tip / Probabilities Low understanding not likely to have capacity Appreciation better test in psychiatric patients Reasoning better test in medical patients