Assessment of Decisional Capacity
By Barton W. Palmer, PhD |
November 1, 2007
Dr Palmer is associate professor of psychiatry in the division of geriatric psychiatry at the University of California, San Diego, and research scientist at the San Diego Veterans Medical Research Foundation. He reports that he has no conflicts of interest concerning the subject matter of this article.
Implementing assessment into clinical practice
Many of the best instruments for assessing capacity to consent to treatment routinely require 20 minutes or more to administer. Given the time constraints placed on many clinicians, routine use of such instruments with every patient may not be a viable option. However, the decision whether to incorporate such instruments into everyday practice need not be viewed as a dichotomous choice but rather as a graded series of options.
At the most basic level, some assessment of patient comprehension can and should be included in nearly every consent discussion with the patient. Incorporating a few basic queries into the initial information disclosure and discussion can be invaluable in identifying and quickly rectifying any initial patient miscomprehension.26,27 For instance, patients can routinely be asked to explain in their own words what they understand about the nature, purpose, risks, and alternatives to the proposed treatment. Ideally, the content of the initial and scoring criteria for such questions can themselves be standardized.26 Based on the response to such initial inqui-ries, the need for more comprehensive assessment may become apparent. Patients with marked cognitive impairments may warrant use of more comprehensive assessments before treatments are prescribed for which there is a likelihood of harm from errant decisions.
The need to explicitly assess and document capacity to consent to treatment for patients may arise even more frequently or saliently in geriatric psychiatry settings. Specifically, concern about decisional capacity may be due to a variety of factors, such as:
- Normal age-related changes in cog-nitive functioning.
- Neurocognitive deficits that are associated with some neuropsychiatric conditions.
- Increased prevalence of neurodegenerative conditions among older persons.
Moreover, because of increased physical frailty and vulnerability to medication side effects, along with increased rates of medical comorbidity and polypharmacy, patients in geriatric psychiatry clinics may face mulifaceted treatment regimens, and thus, complex risk-to-benefit profiles. Empirical data clearly demonstrate that it would be inappropriate to assume either the presence or the absence of decisional capacity solely on the basis of age, diagnosis, or similar risk factors. That is, decisional capacity is appropriately evaluated on a person-by-person (and decision-by-decision) basis. But consideration of risk factors can be helpful in deciding when routine use of more comprehensive assessments may be warranted.
Once the decision to use a capacity instrument has been reached, one is still faced with the dilemma of choosing among the various available instruments. Based on the degree of empirical support, its adaptability to a variety of situations, and the availability of a comprehensive published manual and other training materials for administration and scoring, our research group recently recommended the MacArthur Competency Assessment Tool for Treatment as the best generic choice.13 However, we also acknowledged that none of the instruments are perfect, and there are situations in which another instrument may be a better choice. (For detailed discussion and recommendations, please see the report by Dunn and colleagues.13) Few of the instruments provide definitive "cut-scores," and the ultimate determination of whether a patient has sufficient capacity to consent still depends on professional judgment.28,29
Even when an individual is found to lack sufficient capacity to make a particular decision, additional assessment may be helpful in clarifying the nature of his decision-making difficulty. Although neuropsychological tests do not provide a direct measure of capacity to make a specific choice, consideration of the overall pattern of a person's neuropsychological strengths and weaknesses can be helpful in understanding the neurophysiological source of any cognitive deficits as well as in understanding which specific information processing abilities are suboptimal.30 Such information can be exceptionally helpful in developing compensatory strategies, including enhanced consent procedures.31
- Dunn LB, Nowrangi M, Palmer BW, et al. Assessing capacity to consent to treatment and research: a review of instruments. Am J Psychiatry. 2006;163:1323-1334.
- Palmer BW, Dunn LB, Appelbaum PS, et al. Assessment of capacity to consent to research among older persons with schizophrenia, Alzheimer disease, or diabetes mellitus: comparison of a 3-item questionnaire with a comprehensive standardized capacity instrument. Arch Gen Psychiatry. 2005;62:726-733.
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