Huh, what?! Why? When?!? How? Where!?!...Decisions, decisions, decisions...Capacity vs Competence.

I'm often asked to assess a patient's decision-making capacity, and have come across so many patients and families who don't understand the basics of this pretty complex task. Quite often, this assessment is done in the context of a patient who, unfortunately, may have a moderate to advanced cognitive impairment or advanced psychiatric illness. S/he may also be facing issues managing themselves independently in the community with regard to their medical and other matters. However, they may never have appointed powers of attorney for general and/or healthcare purposes, and now their advocates may need to seek guardianship to ensure appropriate decisions are made for them. This is naturally a pretty stressful situation and the more one understands about it, the easier it is to navigate this winding path.

In the United States, physicians have a basic set of guiding principles when it comes to medical ethics and our approach to practice. And, at the heart of these, is patient autonomy which means that we want to prioritize a patient's ability to make and express decisions for himself/herself. So, when we start assessing for capacity and potentially, incapacity, it's a serious undertaking with many consequences that have to be considered.

Let's start with some basic definitions-

• Capacity is the ability to make a decision for yourself- whether it's medical, financial, or dispositional (e.g. where to live, what help you may need, etc.). The assessment of capacity is a CLINICAL evaluation, often requiring two physicians to certify its status. The physicians do not have to be psychiatrists, but they should be providers familiar with this issue. Capacity is also situation specific- that means someone can have capacity in one realm, but not in another. It can also fluctuate with time- for example, a person with cognitive impairment may be clear and have capacity at one time, but several weeks or months later, if the cognition changes, s/he may not have capacity anymore. So you can see how this is a very complex and nuanced issue.

• Competence is the ability of an individual to participate in legal proceedings. It is a LEGAL term and assessment. To determine competence, you need a legal hearing with presentation of evidence, and a judge to definitively make the decision. Physicians do NOT do assessments of competence.

  
  

So, when a consultation is requested of a physician regarding decision making, the question should be, "Doc, we need help determining 'X's' decision-making capacity," not "Doc, we need to know if X is competent or incompetent.

But, when do you need a capacity evaluation? Here are some triggers to consider a consultation...when the person in question-

• Is not able to voice his/her decisions

• Is simply accepting or refusing care without seeming to think it through...especially complex things. S/he doesn't seem to question the treatment or recommendations offered.

• Is repeatedly, excessively, or inconsistently refusing care

• Has a new inability to manage his/her activities of daily living

• Seems hyperactive, disruptive, or agitated

• Seems to have a very labile/volatile mood

• Is hallucinating or is clinically intoxicated

Many of these situations may be more pertinent to an acute situation such as a hospital, ER, or office practice setting. However, when the problems seem more pervasive and impacting their day to day ability to manage safely, that's when a general decision making capacity evaluation can help.

How do I approach a capacity evaluation/consultation?

• Start with a good review of the person's medical history, psychiatric history & medications.

• Assess the question being asked and what the specific situation is.

• Assess who is involved in this process besides the patient- often there may be throny dynamics between conflicting parties to navigate.

• Try to understand what this person's values and cultural perspectives have been because these can influence decisions.

• Get a sense of what their pattern of decision making has been

• A good physical & especially cognitive/mental status exam.

• Ensure that any barriers to communication are eliminated/minimized- e.g. hearing loss, vision impairment, language discordance.

• Does this person understand the information being presented?

• Does s/he appreciate what the risks/benefits & alternatives are?

• Can s/he express this understanding & appreciation clearly & consistently during the evaluation?

• Is his/her decision making consistent & logical?

And most importantly, we always have to remember, that dementia does NOT mean a person can't make decisions for themselves. Yes, it can impact decision making capacity, but it should not be assumed (remember how assume is spelled...).

So, if you have a loved one who you're concerned about when it comes to decision making capacity, reach out and I'm happy to help out and provide some guidance for you to navigate this tricky path.

References:

1. Libby C, Wojahn A, Noclini JR, & Gillette, G. Competency and Capacity. StatPearls- NCBI Bookshelf, a service of the National Library of Medicine, National Institutes of Health. Updated 5/29/2023.

2. Jones RC and Holden T. A guide to assessing decision-making capacity. Cleveland Clinic Journal of Medicine. December 2004, 71(12): pp. 971-975.

3. Barstow C, Shahan B and Roberts M. Evaluating Medical Decision-Making Capacity in Practice. American Family Physician. July 1, 2018; 98(1): pp. 40-46.