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TOPICS In Geriatric Medicine and Medical Direction – Volume 35 Issue 4 – April 2014 A Peer Reviewed Journal of the Minnesota Medical Directors Association Assessment of Capacity to Make Medical Decisions By Matthew R Kruse, MD and Jan E Apple, MD ____________ ________________________ Capacity is a term that, referred to in this paper in a medical context, describes a patient’s ability to participate in medical decision-making. In practice, clinical decisions are of varying complexity with differing degrees of risk and benefit. For instance, a patient with moderate dementia who might be able to consent to a low risk decision, such as taking antibiotics for an infection, may not have the ability to weigh the pros and cons of a high risk medical procedure with unclear benefit, such as bypass surgery. Capacity assessments do not gauge global functioning, but instead seek to determine if a patient is capable of making a specific, informed choice regarding an intervention consistent with his or her true priorities and values. In the majority of cases, capacity is implicit; in the absence of evidence to the contrary, which may subsequently threaten a patient’s wellbeing, a health care provider typically assumes a patient has capacity to make a decision. Such an approach simultaneously prioritizes patient autonomy (the right for a patient to make his or her own decisions) while generally maintaining patient beneficence (the ultimate welfare of a patient) (1). There are situations, however, when a patient's ability to make decisions may be impaired, which exposes them to risks, procedures, or outcomes that may be inconsistent with that individual's values. In these cases, a careful assessment of a patient’s capacity must be completed before acting upon that patient’s wishes. Psychiatrists are often consulted to complete such an evaluation: up to 25% psychiatric MMDA TOPICS in Geriatric Medicine and Medical Direction consultations are for capacity evaluations, a percentage that may be increasing over time (2). In many cases, however, a patient’s primary physician or treatment team may be the most qualified to assess capacity. For this reason, it is important for all clinicians to know both when to assess capacity and how to assess capacity. This article will review both points and outline appropriate clinical responses to such assessments. Finally, a few case examples will be presented to illustrate key points regarding capacity. When to assess capacity In their authoritative 1998 clinical guide, Grisso and Appelbaum (3) highlighted four reasons providers should consider assessing capacity: 1) Acute change in mental status. There is an extensive list of acute medical issues including delirium, stroke, and hypoglycemia that can impact an individual’s cognition. In fact, literature has demonstrated rates of delirium in hospitalized geriatric patients to be as high as 60% (4). A change in a patient’s cognition may subsequently affect their ability to make care decisions. In such cases, attempts should be made to treat medical issues contributing to altered mentation and restore patients to baseline (if possible) before involving them non-emergent care decisions. 2) Unexpected refusal of recommended treatment. As previously mentioned, assessment of capacity aims to balance patient beneficence with autonomy. A patient has the right to refuse 1 April 2014 recommended medical interventions if they have capacity. Providing a clear rationale for such a refusal, however, should be expected and required. Inability or refusal to do so should raise suspicion that a patient lacks understanding of their medical situation, be influenced by illogical thought processes, or not understand the consequences of their refusal. 3) Unexpected consent for high-risk intervention. Similar to cases of refusal, care must be taken to ensure a patient is making decisions based on a thorough knowledge of his or her situation, consistent with his or her ideals and values. Hasty consent or requests for unorthodox interventions may reflect any number factors that violate the standards of capacity, including lack of understanding of risks and benefits, or unquestioning acceptance of a provider’s recommendations. 4) Patient represents at-risk demographics. Some factors absolutely preclude patient autonomy, such as in the cases of a parent providing consent on behalf of a child, or an adult with a court-appointed guardian. Similarly, some diagnoses raise the risk for impaired decisionmaking, including dementia, psychosis, and brain injury. Regardless of diagnosis, concern for incapacity still warrants a formal assessment, as no diagnosis automatically implies incapacity. Although any of the above scenarios may raise suspicion and lower the threshold for assessment of capacity, none of them necessarily mandate such an assessment. Magid, et al. (5) proposed a three dimensional model to suggest how confident a clinician should be of a patient's capacity. In essence, when a patient’s decision seems to coincide with an unfavorable risk/benefit scenario, a clinician should take extra care to ensure the patient making such a decision has capacity to do so. See Figure 1. MMDA TOPICS in Geriatric Medicine and Medical Direction Figure 1. Determination of threshold to assess capacity The above conditions serve as general guidelines for outlining when to assess capacity. Ultimately, however, it is up to the clinician to decide whether to proceed with a capacity assessment. When a capacity assessment is deemed necessary, there are several accepted methodologies available. How to assess capacity When assessing capacity, whether relying on a clinical interview or a standardized assessment tool, it is critical to implement an organized, systematic approach. When establishing capacity by interview a patient should be able to complete four distinct tasks (3, 6). Each task is described below, with sample questions a clinician might ask to assess a patient’s ability to complete each task. Because each patient’s situation is unique, questions may need to be tailored to optimize relevance. 1. Express awareness of the situation. A treatment provider has a responsibility to explain the clinical situation to a patient before expecting him or her to participate in care. A capacity evaluation should initially verify that this information has indeed been provided to the patient. If it has, is the patient able to identify his or her diagnosis? Even if a provider has carefully provided information to a patient, he or she still may not express awareness of the clinical scenario due to any number of reasons, including denial or altered cognition. If a patient correctly identifies the clinical situation or diagnosis, does he or she comprehend the relevant information involved in making a treatment decision? Critical details include the 2 April 2014 risks and benefits of accepting treatment, risks and benefits of refusing treatment, and identifying additional care alternatives. consistent choice. Inconsistency in preferences or repeatedly changing one’s mind may occur for a variety of reasons, including ambivalence, psychiatric illness, or delirium. Regardless of cause, until a choice can be clearly and consistently expressed, a patient cannot be considered to have capacity. “What is your main medical problem right now?” “Explain why you’re currently in the hospital.” 2. Comprehend the basic facts. If a patient correctly identifies the clinical situation or diagnosis, does he or she comprehend the relevant information involved in making a treatment decision? A patient should be able to identify critical details including the risks and benefits of treatment, risks and benefits of refusing treatment, and identifying additional care alternatives. If a patient is unable to complete any of the above four tasks, they do not have capacity to make a specific decision. In many cases, a non-standardized clinical interview gauging the above abilities will be sufficient in establishing a patient’s capacity. In more difficult or ambiguous situations, especially when clinical risks are higher or with potential involvement of the court system, standardized assessment tools that collect objective data may be preferable to an unstructured clinical interview. The Aid to Capacity Evaluation (ACE) and the MacArthur Competence Assessment Tool (MacCAT) are two widely implemented capacity assessment tools. They provide objective scores based on similar criteria for establishing capacity described above. In practice, the ACE can be completed relatively rapidly, typically within five to ten minutes. The MacCAT is more involved and requires approximately 30 minutes to administer and score, but tends to be more detailed and more sensitive in identifying patients who lack capacity (6, 7). Regardless of methodology, patient autonomy and patient beneficence are key foundations of medical ethics (1) and favoring autonomy at the cost of beneficence, or vice versa, is a decision that no provider should ever take lightly. Accordingly, careful documentation of methods and conclusions regarding capacity is critical. “What treatment was recommended for this problem?” “If you receive this treatment what will happen?” “If you do not receive this treatment what will happen?” 3. Manipulate the information. As previously mentioned, the medical community should uphold patient autonomy whenever possible. As a corollary, a patient with capacity has the right to refuse treatments even if understood to be of low risk and high benefit. In order to do so, however, patients must be able to integrate tasks one and two above and explain how they arrived at their ultimate choice, walking through their decision making process with a provider. The capacity assessor should understand why a patient perceives the risks and benefits of his or her choice to be superior to the risks and benefits of alternative options. This task allows a patient to place a given decision within the context of his or her personal values, priorities, and goals. How to implement findings The methods described above should allow a provider to gather relevant information and reach a thoughtful conclusion regarding a patient’s capacity. If a provider is confident that a patient has capacity to make a decision, the patient’s decision should be honored. If a clinician determines a patient does not have capacity to make a specific “Why have you decided to receive (or not receive) this treatment?” 4. Communicate a choice. Ultimately, a patient with capacity should be able to communicate a MMDA TOPICS in Geriatric Medicine and Medical Direction 3 April 2014 treatment decision, then a surrogate decision-maker is required (8). In emergent cases, consent can often be inferred based on the circumstances of a situation and need not be explicitly granted by a patient. This form of consent, otherwise known as implied consent, often prevails in cases such as first aid. In more complex emergent scenarios, when guidance by a patient’s advance directive or family member is not feasible, a physician must refer to institutional policies. Laws vary across regions, and specific policies differ between institutions. It is important for all providers to regularly review and understand their institutional policies for emergent situations. If a patient is found to lack capacity in a nonemergent situation, an advance directive should guide treatment. If no advance directive is available, a surrogate decision-maker must be sought. Typically, members of a patient’s family will serve as surrogates. In some cases, however, family members may disagree on treatment decisions. Often, state law will define a hierarchy of decision makers, specifying who should guide treatment in cases of disagreement. Some states, including Minnesota, do not have a defined hierarchy. In these cases, when a patient’s family is unable to agree on a treatment decision, the court system may need to be involved to identify a guardian. Regardless of methodology, a surrogate decision-maker should intervene as he or she decides is reasonable and most likely consistent with the patient’s wishes at baseline. Finally, there are non-emergent situations that remain ethically ambiguous even when a surrogate decision maker has been identified and expresses a clear decision. In such cases, an institution’s ethics committee should be consulted to evaluate the case and provide recommendations. capacity to make the decision to discontinue dialysis. In the capacity assessment, she endorsed hopelessness and stated she was not deserving of hospital resources. She did not have psychotic symptoms or suicidal ideation. She was given the diagnosis of depression NOS, and appropriate treatment was recommended. Ms. X was urged to reconsider her decision until psychotherapy and medication could be started, but she continued to refuse all treatment. The psychiatrist felt that the patient lacked capacity to make a decision about dialysis due to severe depression limiting her ability to weigh the risks and benefits of treatment. Ms. X did not have an advanced directive, so the next-of-kin, her adult daughter, acted as her surrogate decision-maker. The daughter wished to continue dialysis for her mother. The hospital ethics committee met with the daughter (the patient refused to participate in the meeting) and after much discussion, it was decided that "forced" dialysis would not be ethical or practically feasible. Courtmandated ECT was considered but not pursued as the patient was too medically unstable for this treatment. The patient and her daughter were provided with support and Ms. X was placed on a hospice unit where she eventually died. In this scenario, appropriate action remained unclear despite proper identification of a surrogate decision-maker and her choice to pursue treatment. Involvement of an ethics committee in this case was both appropriate and critical in formulating the optimal course of action and overriding the daughter’s wishes. Case 2 Mr. Y was a 92-year-old white male with a history of dementia. He was able to live independently with little assistance. He was admitted to the hospital for abdominal pain and it was determined that he had a perforated bowel. Surgery felt that he required a bowel resection and colostomy and would likely need nursing home placement. The patient refused surgery. Psychiatry was consulted as it was not clear if the patient had the cognitive ability to make a decision about surgery. Case 1 Ms. X was a 45-year-old American Indian female with no known psychiatric history. She was admitted to the Medicine Service for symptoms related to renal failure. She had been receiving dialysis for the past 5 years due to complications of diabetes mellitus. The patient refused dialysis, stating that she wanted to die. A psychiatry consult was obtained to assess her MMDA TOPICS in Geriatric Medicine and Medical Direction 4 April 2014 Mr. Y was oriented to self, place, date, and reason for hospitalization. The surgeon carefully and repeatedly explained the risks, benefits and alternatives to surgery. When asked why he was refusing surgery, the patient stated "because I will die". He was not able to recall that he would likely die without surgery and seemed unaware of the inherent risks of the surgery. Psychiatry determined that Mr. Y lacked capacity. He did not have an advanced directive, so his son was contacted in accordance with the state’s established surrogate hierarchy. He was willing to act as the patient’s surrogate although he had not seen his father in several years. It was determined that he had his father's best interests in mind and was aware of the patient's values. Mr. Y had expressed in the past that he would never want to be in a nursing home, and his son felt that the patient would not want to have surgery. The patient was provided comfort measures only. Ultimately, the perforation sealed and the patient was able to return home with an increase in home care services. The above case highlights the role for surrogate hierarchy as well as the overarching goal of acting in accordance with a patient’s goals and values at a time when they would have had capacity. information provided by his providers. His decision to refuse treatment was based on a delusion. He was given forced IM antipsychotic medication, sedated, and received surgical repair. It was later discovered that the patient had a history of schizophrenia. When he became medically stable he was transferred to an inpatient psychiatry unit and was civilly committed. This scenario highlights the importance for a patient to meet all requirements for capacity. Failure on any of the four tasks outlined above indicates a lack of capacity. Conclusions Every care decision should be made by an individual with capacity to make that decision. In most cases, the patient is assumed to have capacity. When suspicion that a patient lacks capacity is sufficiently high, or the threshold to establish capacity is sufficiently low (see Figure 1) a variety of methods have been described to assess capacity. If a patient lacks capacity, care decisions should be guided by an advance directive or, if no such directive exists, a surrogate decision maker. In more complex or difficult cases, a treatment team should consider consulting psychiatry or an ethics committee to clarify appropriate action. Ultimately, the overarching goal is to allow a patient’s values and priorities guide all treatment decisions, upholding the ideals of patient beneficence and autonomy. Case 3 Mr. Z was a 35-year-old white male who was seen in the emergency department for a partially severed penis. He had no known psychiatric history as he refused to provide any personal information to the treatment provider. The patient stated that he was instructed by the Bible to "cast off" something offensive from his body. A psychiatry consult was obtained to assess the patient's capacity to make a decision about surgical repair of his penis. Mr. Z was noted to be disheveled and malodorous. Interview revealed multiple religious delusions. He knew why he was in the hospital and understood the risks, benefits, and alternatives for treatment of his condition. He refused surgical repair of his penis as he felt he needed to comply with a passage from the book of Matthew in the Bible. Psychiatry determined the patient lacked capacity as he was not able to rationally manipulate MMDA TOPICS in Geriatric Medicine and Medical Direction About the Authors First Author: Matthew R Kruse, MD Title: Psychiatry Resident, University of Minnesota Second Author: Jan E Apple, MD Title: Psychiatrist, Minneapolis Administration Health Care System Veterans References 1) Gillon, R. (1994). Medical ethics: four principles plus attention to scope. BMJ: British Medical Journal, 309(6948), 184–188. 2) Jourdan, J. B., & Glickman, L. (1991). Reasons for requests for evaluation of competency in a municipal general hospital. Psychosomatics, 32(4), 413–6. 3) Grisso, T., & Appelbaum, P.S. (1998). Assessing competence to consent to treatment: a guide for 5 April 2014 physicians and other health professionals. New York: Oxford University Press; 1998. 4) Pandharipande, P., Jackson, J., & Ely, E. W. (2005). Delirium: acute cognitive dysfunction in the critically ill. Current Opinion in Critical Care, 11(4), 360–8. 5) Magid, M., Dodd, M. L., & Bostwick, J. M. (2006). Is your patient making the “wrong” treatment choice? Current Psychiatry, 5(3). 6) Tunzi, M. (2001). Can the patient decide? Evaluating patient capacity in practice. American Family Physician, 64(2), 299–306. 7) Grisso, T., Appelbaum, P. S., & Hill-Fotouhi, C. (1997). The MacCAT-T: a clinical tool to assess patients’ capacities to make treatment decisions. Psychiatric Services (Washington, D.C.), 48(11), 1415–9. 8) Appelbaum, P. (2007). Assessment of patients’ competence to consent to treatment. New England Journal of Medicine, 357(18), 1834-1840. President’s Letter I attended the American Medical Directors Association annual meeting in Nashville, Tennessee, from February 27-March 2. I and the other geriatricians representing Minnesota helped the House of Delegates address and pass the following issues that are now AMDA policy: 1) E-cigarettes should be considered as tobacco products in nursing homes; 2) AMDA will initiate discussions with hospital and hospitalist organizations to make them aware of the need for appropriately written prescriptions for controlled substances when a resident is discharged to a nursing home; 3) AMDA will promote POLST; 4) AMDA will work to help develop ideal bidirectional electronic message and document exchanges for nursing homes; 5) AMDA will work with the Centers for Medicare & Medicaid Services (CMS) and other stakeholders to address the issue of appropriate use of Quality Indicators for the nursing home population; 6) AMDA will develop mechanisms to create, aggregate, and promote easy access to existing and new practical tools for use in the post-acute and long-term care continuum; and 7) AMDA will communicate to CMS that the Beers Criteria are intended to be guidelines for prescribing and not a regulation intended to encroach on the practice of medicine and have them convey that to state surveyors and pharmacy benefits managers. MMDA’s resolution that recommended “the elimination of any pharmaceutical support for the AMDA Long Term Care Annual Meeting, when that support includes direct pharmaceutical marketing of medications or the company's name to conference attendees, and replacing that financial support with alternative educational conference funding sources” did not pass. I was surprised by the resistance to this idea by HOD attendees. I think their strongest argument was that it was the attendees’ impression that AMDA was already trying to do this…and I would agree. However, If there is support amongst the delegation, next year we might return the resolution to the HOD and make sure that it suggests specific timelines about when those goals should be met and a request that AMDA help the state chapters (like MMDA) figure out how to meet similar goals. The biggest news out of the HOD was that the AMDA Bylaws Amendments passed as proposed, which resulted in many changes, including the following: 1) a new name—AMDA: the Society for Post-Acute and Long-Term Care Medicine; 2) a new mission statement; 3) the addition of NPs and PAs to full membership, allowing them positions on the Board of Directors; and 4) officers (therefore leadership), however, must remain physicians. MMDA is dedicating this year to developing a strategic direction for MMDA. I am hoping that we might utilize some of these changes as a template for structural changes to MMDA that would help us meet the needs of geriatricians in Minnesota in the coming years as well. We will be starting that discussion at the March MMDA Board of Directors meeting. I will keep you posted as to how these ideas develop. Please forward to Rosemary Lobeck, the MMDA executive director at [email protected], any thoughts or ideas that you have about how a statewide organization might best be structured to support your geriatric practice for the frail elderly in Minnesota and/or the region. George Schoephoerster, MD President MMDA MMDA TOPICS in Geriatric Medicine and Medical Direction 6 April 2014 Minnesota Nursing Home Quality Update- April 2014 CMS Releases QAPI Process Tools In a collaborative effort with the University of Minnesota and Stratis Health, subject matter experts, consumer groups, and nursing home stakeholders, the Centers for Medicare and Medicaid Services (CMS) created “process” tools that may be used to implement and apply some of the basic principles of Quality Assurance Performance Improvement (QAPI). These process tools were recently published by CMS within a Process Tool Framework. This framework has been created to crosswalk each CMS Process Tool to the QAPI Five Elements. A description of the purpose or goal for each tool is hyperlinked within the framework. Click here for A Process Tool Framework. One of the tools that may be of interest to nursing home Medical Directors is Examples of Performance Objectives for Job Descriptions and Performance Reviews. This tool includes these suggestions on how medical directors can assist nursing homes in their efforts: Receive direction from the owner/board of directors on QAPI goals and clearly communicate these to staff Communicate regularly on the progress of QAPI work to the owner/board of directors, employees and other stakeholders Establish overall QAPI objectives for the organization and assign responsibility for their fulfillment Accept responsibility and oversee development of QAPI plan, including policies for ensuring that QAPI activities are given high priority in the overall management of facility operations Foster an organization-wide commitment to quality assurance and performance improvement both verbally and non-verbally (i.e., via actions and attitude) Allocate sufficient financial, material, and human resources, including training, to carry out QAPI activities Ensure QAPI in the organization includes a mechanism for obtaining resident and family input to consider as potential areas for improvement Create and maintain a consistent process (e.g., scheduled rounding, active participation on quality committee) to stay informed of all QAPI efforts underway, including their progress and achievements Provide oversight and enthusiastic support of QAPI activities For more information about QAPI, contact Jane Pederson, MD, Stratis Health, [email protected]. MMDA TOPICS in Geriatric Medicine and Medical Direction 7 April 2014 Minnesota Medical Directors Association P. O. Box 24475 Minneapolis, MN 55424 Phone:952-929-9398 Fax: 612-656-3016 Website:www.minnesotageriatrics.org Executive Director: Rosemary Lobeck Editor: Jane Pederson, M.D. E-mail: [email protected] Topics in Geriatric Medicine and Medical Direction is produced and Published bimonthly by the Minnesota Medical Directors Association. Topics in Geriatric Medicine and Medical Direction, the peer reviewed bimonthly publication of the Minnesota Medical Directors Association, is committed to publishing quality manuscripts representing scholarly inquiry into all areas of geriatrics and long term care medical direction and practice. We encourage submissions of geriatric and long term care research, best practices, reviews of literature and essays. Inside Assessment of Capacity to Make Medical Decisions Page 1 President’s Letter Page 6 Minnesota Nursing Home Quality Update Page 7 Manuscripts should be emailed to [email protected] and [email protected]. The first page should include the title and a 50 to 60 word abstract. Manuscripts should range around 1800 to 3000 words. Review Policy: Manuscripts will be reviewed by at least two members of the review board whose evaluations will provide a basis for the publication decision. We are committed to a rapid review process. All rights reserved. Copyright Minnesota Medical Directors Association. Topics may be copied only with prior permission. Contact MMDA at 952-929-9398. MMDA TOPICS in Geriatric Medicine and Medical Direction 8 April 2014