assessing capacity: a primer for the busy healthcare professional michael r. villanueva, psyd,...
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Assessing Capacity: A Primer for the Busy Healthcare Professional
Michael R. Villanueva, PsyD, ABPP-CNProvidence Medford Medical Center
Grand Rounds June 29 2011
Conflicting Goals
Respecting Pt Autonomy
Acting in the Best Interest of the Pt
Approaching the task Who is my cognitively impaired pt? How do I assess the impaired pt? When do I refer? What is the relationship between
being cognitively impaired and incapacitated?
What are the rules regarding medical decision making capacity?
What do I do if pt lacks capacity?
How did we get into this mess? Pts suffer cognitive as well as
physical decline Pts with dementia do not always
appreciate their level of decline Elder pts sometimes have
inadequate social supports and resources
Pts with marginal cognitive function can decline rapidly after episode of delirium
Risk factors for cognitive impairment Age Delirium Cardiovascular disease Head injury Stroke Amputation Dialysis Parkinsons or Parkinsonism Hypoxemia Diabetes Multiple Sclerosis Radiation, chemotherapy
What is the risk of cognitive impairment? Prevalence of dementia 45% after age
85 Prevalence of dementia in pts over 80
with Parkinson’s 69% Significant Cognitive Impairment in MS:
40 to 50% of community dwelling sample
Odds of developing dementia within three mos after CVA: 1 in 4.
Delirium – DSM IV Disturbance of consciousness
Reduced clarity Reduced focus
Change in cognition Development over a short period of
time Caused by medical/physiological
condition Development over short period of time
Disturbance tends to fluctuate during course of the day
Dementia – DSM IV Acquired cognitive impairment due
to brain dysfunction Severity sufficient to interfere with
usual social or occupational function
Deterioration in two or more neuropsychologic domains
Changes must represent decline from previous level
Dementia After Stroke
451 consecutive stroke pts admitted to hospital
Assessed at 3 mos post cva Dementia in 25% of sample
J of Neuol Neurosurg and Psychiatry, 2009 Aug 80(8) 865-70
Delirium after CVA 263 consecutive acute ischemic stroke pts
ages 55 – 85 Delirium in 19% of sample Low ed, pre cva cognitive decline, and stroke
severity were delirium risk factors Post stroke delirium associated with dementia
3 mos post cva Early delirium also associated with reduced
survival
Int J of Geriatric Psychiatry 2011, May 10
Dementia and depression Do not quickly dismiss cognitive
dysfunction because the pt is “just depressed”
VA data base, 281,540 pts (55 and older) reviewed
None had dementia at baseline Those with h/o of depression and
dysthymia were twice as likely to develop dementia Am J Geriatric Psychiatry 2011 May 18
Hospital pts vs. Controls Pts without known cerebral injury
hospitalized on a rehabilitation floor Control: matched community dwelling
individuals Hospitalized pts scored more poorly
than controls on 9 of 10 neuropsychologic tests
PM R 2011 May; 3(5): 426-32
How do I assess cognition?
During history Discussion with caregivers and
family Chart review Mental status exam
History
Vague Inconsistent Poor remote recall not normal
aging
Caregivers and Family
Evidence of change Evidence of tasks being taken over Reports cw apathy Do not be fooled by reports of
depression
Chart review
Med list (are they on Aricept?) Memory concerns Medication non-compliance
Mental Status Exam
MMSE MoCA
MMSE
0 – 30 Covers registration, STM,
orientation, calculations, visuo-motor, language
Weak on executive function Highly reliant on intact language Enjoys broad use
MoCA 0 – 30 Norms for pt groups Covers multiple domains, fluency,
stm, attn/exec, visuo-spatial, naming, abstract reasoning
Canadian (so others are paying for the free lunch)
Less robust assessment of orientation
When should I refer? Standard test score higher than
expected Complicated history needing help with
etiology and prognosis Difficulties getting pt through mental
status screen Dementia mild to moderate and pt has
been getting by marginally When Dr. Dickinson returns from
maternity leave
Therapy Resources PT can help comment on pt’s practical
safety awareness with transfers and ambulation
OT can comment on the pt’s ability to perform important self care activities in a safe manner
SLP can comment on pt’s use of language to express needs, and can comment on pt’s response to treatment to understand level of deficit
My pt is cognitively impaired…
What does that mean regarding medical decision making
Discharge planning Medication management
Be Specific
Know what ability is needed for what task
Six Different Capacities
Medical Capacity Sexual Capacity Financial Testamentary Driving Independent Living Capacity
Basic Underlying Philosophy and Legal Considerations All adults are presumed to have
capacity We all have a “right to folly”
(Justice Douglas) Support pt decisions we disagree
with if pt has capacity Protect pt from dangerous
decisions if pt does not have capacity
References Oregon State Bar Publication Online
(with assistance from Timothy L. Jackle, attorney at law, Foster Denman LLP)
Assessment of Older Adults with Diminished Capacity: A Handbook of Psychologists American Bar Association/American
Psychological Association Assessment of Capacity in Older Adults Project Working Group (available through the APA website)
Assessment of Capacity is part of our clinical assessment
It is part of obtaining consent, and therefore integral to the evaluation of the cognitively impaired pt
Medical Capacity
Capacity means an individual’s ability to understand the significant benefits, risks, and alternatives to proposed health care and to make and communicate a health-care decision
Uniform Health-Care Decision Act of 1993, 1994
Medical Capacity
Decisional Capacity in health care is rooted in the concept of Informed Consent
Such consent must be:CompetentVoluntaryInformed
Medical Consent: Functional Elements
Expressing a Choice Understanding Appreciation Reasoning
Expressing a Choice
Cannot communicate a treatment choice
Vacillate so much that cannot determine pt’s true wishes
Understanding
Often considered to be primary in consideration of medical capacity
The ability to comprehend diagnostic and treatment related information
Appreciation
Ability to relate treatment information to one’s personal situation
Ability to infer possible benefits of treatment and
Accept or believe diagnosis
Reasoning
Ability to state rational explanations
Process information logically
Process information in a consistent manner
Cognitive Underpinnings of Medical Capacity – Expressing a Choice
Need to assess expressive and receptive language
Use yes/no assessmentHave them follow basic commandsAsk them to describe a very recent
event
Understanding
Assess memory What happened earlier today? Where are we? What procedure is scheduled?
Assess comprehension Why are we doing the procedure?
Appreciation and Reasoning
Executive Function and Mental Flexibility Counting backward Verbal Fluency Discuss benefits and risks
Modifying Factors Regarding Medical Consent
Risk of harm Blood Draw vs. CABG
Values Treatment worse than disease Impose Care on family
Consent Capacity Instruments
Aid to Capacity Evaluation (ACE) Semi Structured Interview
Aid to Capacity Evaluation (ACE)Etchells et al (1999)
Provides structured interview to elicit main facets of capacity: Understand the medical problem Understand the treatment Understand alternatives to treatment Understand option of refusing treatment Ability to make decision not based on Psych
Factors Ability to perceive consequences of
Accepting Refusing
Pt is impaired and can not make medical decisions
Now what
Sources of Legal Authority
There is detailed information regarding sources of legal authority for withdrawal of life support
Not as much guidance on discharge to home vs. assisted living
Incapacitated
A condition in which a person’s ability to receive and evaluate information effectively or to communicate decisions is impaired to such an extent that the person presently lacks the capacity to meet the essential requirements for the person’s physical health or safety.
Incapable
Incapable means that in the opinion of the court in a proceeding to appoint or confirm authority of a health care representative, or in the opinion of the principal’s attending physician, a principal lacks the ability to make and communicate health care decisions to health care providers…
Incapacity Ultimately competence is a legal
decision Capacity can not be determined in the
abstract, a person is incapacitated to a specific task
Capacity is interactive and is influenced by demands of environment as well as the individual
Capacity is not necessarily static
Presumed Competent
A lawyer should presume an older client has necessary mental competency to make legal choices
Oregon law presumes a person to be competent absent an adjudication of incompetence
Capacity to perform a particular act is examined at the time of the act
Action Items if Patient Lacks Capacity
Identify Proxy Decision Maker already established
Identify close family able to discuss pattern of wishes
Wait to see if pt “clears” Assess during times of optimal
clarity Involve social services to help
establish appointed decision maker
If Pt is Incapable
Advance Directive (Not pertinent for most of our decision making)
Prior Executed POA If temporary wait and treat Can rely on family members (little
law on the subject)
Power of Attorney Competence to assign power of
attorney akin to competence to enter into contract
“A person can enter into a valid contract if the person’s reasoning ability enables the person to understand the nature of the transaction in which the person is engaged, and to understand its quality and consequences”.
Steps to Take
Temporary guardianship Limited or full guardianship Assess implied consent
Capacity to Live Independently
Limited functional abilities Danger due to
cognitive/psychiatric Cannot accept or use assistance
Functional Components
Activities of Daily Living - ADLs Eating, bathing, toileting
Instrumental Activities of Daily Living – IADLs Higher level: Financial and Household
management
Key ADLs and IADLs
Diet Hygiene Maintain household Transportation Handle emergencies Compensate for deficits
Three part framework to understand living independently
Understanding Able to discuss basic requirements of taking
meds, buying groceries, etc Application
Which tasks can pt perform and which ones can be done by others as directed by the pt
Judgment Pt may be able to discuss need for help, but
does he keep firing caregivers?
Cognitive Predictors of Poor Functional Status
Royall et al (2007) J Neuropsychiatry and Clinical Neuroscience
Literature Review: Cognitive correlates of ADLs and IADLs
Domain specific cognitive function weakly associated with functional outcome
General Cognitive Screening measures moderately associated with ADL/IADL success (MMSE)
Failure to Remain in the Home
Night Time Activity
Immobility
Incontinence
Importance of Modifying Factors Diagnosis/Prognosis
Is the state of lack of capacity temporary?
Risk of Harm Is the decision likely to have much impact?
Undue Influence Is the patient under the control of others?
Environmental/Social Support Can the potentially harmful decision be corrected by
supervision?
Guardianship
In Oregon law, courts can impose guardianship when a pt becomes incapacitated
Incapacitated: Unable to make or communicate
decisions necessary to provide for person’s basic physical health and safety
Guardianship requires 3 considerations
Disabling condition
Functional disability
Cognitive impairment
SummaryIdentify cognitively impaired ptsUse base rates to raise awareness and alertnessAssess Pts with suspicion of impairment with
mental status examRefer pts when doubt remains regarding
cognitive function, implications, and etiologyHelp determine whether or not the level and
type of cognitive difficulty affects competenceAssist in clinically improving capacity, defer to
proxy decision maker, or allow the wishes of a competent pt AMA