Evaluating Medical Decision-Making Capacity in Practice

 

Am Fam Physician. 2018 Jul 1;98(1):40-46.

Author disclosure: No relevant financial affiliations.

Medical decision-making capacity is the ability of a patient to understand the benefits and risks of, and the alternatives to, a proposed treatment or intervention (including no treatment). Capacity is the basis of informed consent. Patients have medical decision-making capacity if they can demonstrate understanding of the situation, appreciation of the consequences of their decision, and reasoning in their thought process, and if they can communicate their wishes. Capacity is assessed intuitively at every medical encounter and is usually readily apparent. However, a more formal capacity evaluation should be considered if there is reason to question a patient's decision-making abilities. Such reasons include an acute change in mental status, refusal of a clearly beneficial recommended treatment, risk factors for impaired decision making, or readily agreeing to an invasive or risky procedure without adequately considering the risks and benefits. Any physician can evaluate capacity, and a structured approach is best. Several formal assessment tools are available to help with the capacity evaluation. Consultation with a psychiatrist may be helpful in some cases, but the final determination on capacity is made by the treating physician. If a patient is found not to have capacity, a surrogate decision maker should be identified and consulted. If the patient is unable to give consent and identifying a surrogate decision maker will result in a delay that might increase the risk of death or serious harm, physicians can provide emergency care without formal consent.

Informed consent involves providing patients with accurate and adequate information about the risks, benefits, and alternatives of a treatment in a manner that is free from coercion. It also requires that patients have medical decision-making capacity. Medical decision-making capacity has four key elements. Patients must be able to (1) demonstrate understanding of the benefits and risks of, and the alternatives to, a proposed treatment or intervention (including no treatment); (2) demonstrate appreciation of those benefits, risks, and alternatives; (3) show reasoning in making a decision; and (4) communicate their choice.1,2

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

A structured approach should be used when assessing a patient's decision-making capacity. This should include an assessment of any language or communication barriers interfering with the patient's understanding; identification and treatment of any reversible causes of incapacity; a directed interview to assess the elements of consent; and, if needed, the use of a formal tool to assess capacity and cognition.

C

3, 7, 8

Use of a formal assessment tool such as the Aid to Capacity Evaluation improves accuracy in determining a patient's decision-making capacity.

C

2, 8

Use of a standard cognitive assessment instrument is helpful in assessing for capacity when patients score at the extremes of the scale (very high score favors capacity and very low score favors incapacity).

C

2, 15


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

A structured approach should be used when assessing a patient's decision-making capacity. This should include an assessment of any language or communication barriers interfering with the patient's understanding; identification and treatment of any reversible causes of incapacity; a directed interview to assess the elements of consent; and, if needed, the use of a formal tool to assess capacity and cognition.

C

3, 7, 8

Use of a formal assessment tool such as the Aid to Capacity Evaluation improves accuracy in determining a patient's decision-making capacity.

C

2, 8

Use of a standard cognitive assessment instrument is helpful in assessing for capacity when patients score at the extremes of the scale (very high score favors capacity and very low score favors incapacity).

C

2, 15


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

Capacity differs from competence. Although the terms are often used interchangeably, competence is a legal term that is determined by the court system, whereas capacity is a medical term that is determined by the treating physician. According to their strict definitions, lack of competence refers to global decision-making impairment (e.g., finances, property,

The Authors

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CRAIG BARSTOW, MD, is program director of the hospital medicine fellowship at Womack Army Medical Center, Fort Bragg, N.C., and an assistant professor of family medicine at the Uniformed Services University of the Health Sciences, Bethesda, Md....

BRIAN SHAHAN, MD, is a hospital medicine fellow at Womack Army Medical Center.

MELISSA ROBERTS, MD, is a faculty member in the Family Medicine Department at Womack Army Medical Center.

Address correspondence to Craig Barstow, MD, Womack Army Medical Center, 2817 Reilly Rd., Fort Bragg, NC 28310 (e-mail: craig.h.barstow.mil@mail.mil). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

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1. Uniform H-CDA. National Conference of Commissioners on Uniform State Laws, August 1993. http://www.uniformlaws.org/shared/docs/health%20care%20decisions/uhcda_final_93.pdf. Accessed March 25, 2018....

2. American Bar Association, American Psychological Association. Assessment of older adults with diminished capacity: a handbook for psychologists. http://www.apa.org/pi/aging/programs/assessment/capacity-psychologist-handbook.pdf. Accessed February 22, 2018.

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10. National Ethics Committee of the Veterans Health Administration. Ten myths about decision-making capacity. 2002. https://www.ethics.va.gov/docs/net/NET_Topic_20021120_Ten_Myths_About_DMC.doc. Accessed March 25, 2018.

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16. Berg JW, Appelbaum PS, Grisso T. Constructing competence: formulating standards of legal competence to make medical decisions. Rutgers Law Rev. 1996;48(2):345–371.

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