HIMT310 Healthcare Systems and Organizations

Conceptual Background and Rationale for Curriculum: Evaluation of decision-making capacity (DMC) is a clinical challenge faced by many mental health providers. Questions regarding capacity commonly arise in numerous specialties, including internal medicine, obstetrics/gynecology, surgery, and neurology. Requests for a detailed capacity evaluation may be directed to consultants in psychiatry. The goal of this curriculum is to help you learn the concepts and skills necessary to perform a capacity evaluation that is both efficient and sufficiently comprehensive. Step 1: Read: Evaluating DMC - A Primer on Concepts (1).docx Step 2: Read, choose one of the cases and answer the questions posed on your chosen case from Evaluating DMC - Cases.docx . No more than 1 - 2 pages, please.

 Goal: The goal of this assignment is to introduce you to the essential components of evaluating decision-making capacity in patients, and to provide you with opportunities to practice your understanding of these principles through sample cases.

Evaluation of decision-making capacity (DMC) is a clinical challenge faced by many mental health providers. Questions regarding capacity commonly arise in numerous specialties, including internal medicine, obstetrics/gynecology, surgery, and neurology. Requests for a detailed capacity evaluation may be directed to consultants in psychiatry. The goal of this curriculum is to help you learn the concepts and skills necessary to perform a capacity evaluation that is both efficient and sufficiently comprehensive.

Read: Evaluating DMC - A Primer on Concepts (1).docx

Read, choose one of the cases and answer the questions posed on your chosen case from Evaluating DMC - Cases.docx. No more than 1 - 2 pages, please.Attribution for source material.

As many trainees may remember from ethics training or self-directed study, decision-making capacity is generally not considered to be equivalent to competency.  Competency is a more global descriptor that is determined in a court of law; although there can be variability in the definition of “competency,” it typically describes a person’s ability to care for himself/herself and make decisions about a broad range of topics. In contrast, decision-making capacity describes the ability to make a specific decision at a specific time.

Unlike a determination of competency, decision-making capacity can be fluid and may change over the course of an illness or treatment. As an example, a patient who is lethargic upon initial presentation may not have decision-making capacity when admitted, but, if successfully treated, may regain capacity to make decisions over the course of his or her hospitalization.

It is also possible for an individual to have capacity to make one decision, but not another, at the same time. As an example of this, a patient with mild cognitive impairment may be able to fully grasp the relative risks and benefits of a recommendation to begin a medication s/he already has familiarity with and has taken previously, but may not be able to understand the potential risks and benefits of a complex procedure. In this example, a patient may be more likely to have decision-making capacity in the first scenario, but not the latter.

Given that decision-making capacity can fluctuate over time, these four elements need to be assessed on an ongoing basis.

Let’s look at these requirements a little more closely to understand what they mean. The first requirement, the ability to understand the pertinent medical information, means that the patient is able to comprehend essential medical information delivered by his or her team, including the nature of his/her condition, the recommended treatments and alternatives, and relative risks and benefits of treatments (or non-treatment).

 For example, this might involve understanding what “meningitis” means, what an antibiotic is, or what the general approach to a recommended surgical procedure might look like. This does not need to be at the level of understanding or detail that would be expected of a medical professional but should be enough to appropriately evaluate risks and benefits and inform the decision-making process. Some examples of questions that can be asked to help determine if the patient meets this criterion include:

The second criterion, an ability to appreciate one’s situation and potential outcomes, overlaps to some degree with the first criterion described (understanding the relevant medical information).  This second criterion refers to a patient’s ability not just to understand medical information, but also to understand and appreciate how this information applies to his or her own unique situation.

This includes an appreciation for the seriousness of one’s condition and the ability to understand and describe potential consequences of medical choices for one’s particular situation. An example of a situation in which a patient might meet criteria #1 (medical understanding) but not criteria #2 is a patient who expresses understanding and awareness of the risks of refusing treatment in an abstract sense, but also expresses certainty that this outcome would never happen to him or her in particular, without medical evidence to substantiate this belief. Examples of questions to assess this criterion include:

The third criterion, an ability to arrive at a decision by a rational thought process, can be more difficult for doctors to understand and assess. Sometimes, if a patient disagrees with a physician, it is hard for the physician not to think that the patient is irrational. However, as long as there is internal logic and it is consistent with the patient’s usual values and beliefs, a patient’s thought process can be rational even if it is in disagreement with the physician’s recommendation. As an example, a patient may refuse a procedure that carries a 1% risk of serious disability.

This may seem illogical to a physician who knows that the absolute risk of bad outcome is low; however, if the type of disability (e.g. vision loss) is completely unacceptable to the patient, he or she may choose to refuse the procedure based on a logical reflection on his/her values. If not obvious, this can often be assessed by asking why or how a patient arrived at a particular decision. Family members or close supports may also be able to help provide helpful collateral regarding whether a patient’s decision-making process is consistent with his or her usual thought process and values. Examples of questions to assess this criterion include:

The final criterion, the ability to communicate a decision, is more straightforward. It simply requires that the patient be able to communicate a clear preference or decision to providers. The decision also should be consistent, within reason. For example, if a patient expresses frequent inconsistencies or changes in their decision, as might occur in a delirious patient or one who did not truly understand the situation, the patient would likely not meet this criterion. However, , a patient who initially expresses one decision, but then expresses another after additional research on the topic, careful reflection, time to discuss with additional trusted providers, etc ,should have the new decision respected, provided all of the other necessary criteria are met.