Download April 2014: Assessment of Capacity to Make Medical Decisions

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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
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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
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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
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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
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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
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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
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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
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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:
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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
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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
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Inside
Assessment of Capacity to Make Medical
Decisions
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President’s Letter
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Minnesota Nursing Home Quality
Update
Page 7
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