Neurology Book

Delirium

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Medical Decision-Making Capacity

Aka: Medical Decision-Making Capacity, Decision-Making Capacity, Decision Making Capacity Evaluation
  1. See Also
    1. Against Medical Advice
    2. Informed Consent
    3. Consent for Treating Minors
    4. CURVES Mnemonic for Capacity Assessment
    5. Medical Elopement
    6. Competency Hearing
    7. Risk Management
    8. Health Insurance Portability and Accountability Act (HIPAA)
  2. Definitions
    1. Informed Consent
      1. Patient willingly participates in medical therapy
      2. Requires understanding what is involved with the proposed therapy
    2. Mental Competency
      1. Sufficient understanding and memory to comprehend their own situation
      2. Understanding of the consequence of their proposed actions
      3. Competence is determined by a judge
      4. May indicate whether a person may stand trial
        1. Can they distinguish truth from fiction
        2. Can they assist their attorney in their own defense
    3. Medical Decision-Making Capacity
      1. Ability to communicate, understand the information they are given
      2. Ability to make logical decisions based on given information
      3. Ability to understand their current medical status or condition
      4. Ability to understand options for medical care
  3. Indications: Capacity Assessment
    1. Abrupt change in mental status
      1. See Altered Level of Consciousness
    2. Refused recommended treatment without adequate reason
    3. Accept risky treatment without adequate processing
    4. Known risk of impaired decision making
  4. Evaluation: Decision making capacity (See ACE below and Curves Mnemonic)
    1. Does the patient understand condition and treatment?
    2. Can patient apply information to their own condition?
    3. Reasoning consistent with the facts and their values?
    4. Can the patient communicate their choices clearly?
  5. Evaluation: Cognition
    1. Mental Status Examination
    2. Mini-Mental Status Exam (MMSE)
  6. Evaluation: Capacity
    1. CURVES Mnemonic for Capacity Assessment
      1. Mnemonic that can be used quickly at the point-of-care (e.g. Emergency Department) to assess capacity
    2. Aid to Capacity Evaluation (ACE) by Dr. Etchells
      1. Structured interview divided into 7 domains
        1. Patient understands current medical problem, proposed treatment, and alternatives (Domains 1-4)
        2. Patient appreciates consequences of their decisions including withholding treatment (Domains 5-6)
        3. Patient does not have mental illness (Major Depression, Psychosis) impacting their decisions (Domain 7)
      2. ACE Web Resource (freely available for online download)
        1. http://www.jointcentreforbioethics.ca/tools/ace_download.shtml
    3. Hopkins Competency Assessment Test (HCAT)
      1. Competency evaluation based on the reading of a 4 paragraph essay followed by questions
      2. Can be performed in 10 minutes by a non-clinician
    4. MacArthur Competence Assessment Tool for Treatment (MACCAT-T)
      1. Structured interview by clinician with rated responses
  7. References
    1. Herbert, Henry, Arambasick and Orman in Herbert (2014) EM:Rap 14(11): 4-5
    2. Bradford-Saffles and Arambasick (2013) Crit Dec Emerg Med 27(6): 11-5
    3. Etchells (1999) J Gen Intern Med 14:27-34 [PubMed]
    4. Freedman (1991) Ann Intern Med 115:203-8 [PubMed]
    5. Tunzi (2001) Am Fam Physician 64(2):299-306 [PubMed]

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