Decision Making Capacity

May 5th, 2010

Alan Sanders, Ph.D.System Ethicist, Catholic Health East

Director, Center for EthicsSaint Joseph’s Health System

Atlanta, GA

Liz Carson, Ph.D.Staff Psychologist

Saint Joseph’s HospitalAtlanta, GA

A “Theory” of Expertise

The Principle of Decision Making Capacity

Respect for Human Dignity– Informed Consent

• Protection• Right to accept or refuse treatment• Substituted Judgment

– Best Interests– Participation in the Process

From the Beginning……

• Know your state’s law regarding capacity to make health care decisions– Who can declare a patient incapacitated

(physician, social worker)?– How should it be recorded?– What are the criteria?

Ms. White is a widowed 85-yeard-old female with a past medical history of dementia and peripheral vascular disease. She has been admitted to the hospital with an ischemic foot needing amputation. On the way down to surgery she exclaims that she does not want surgery, and so staff return her to her room. Later the surgeon visits her, and later reports that during their discussion, she reemphasized she does not want to lose her foot; she has lived a good life; if it is her time, she is at peace.

Ms. White lives with her son – one of many of her children – and his family. Upon hearing of the cancelled surgery, the son comes to the hospital with a signed advanced directive naming him her authorized surrogate decision maker. He demands that the hospital proceed with the amputation. The surgeon calls an ethics consult and a psych consult.

Delineation of Capacity

• NOT the same as:– competence– impaired mental states

• Patients are presumed to have capacity unless they demonstrate otherwise

• Match between a persons abilities and the demands of the decision

• Sliding scale

Factors that Influence Assessment

• Disagree with recommended treatment

• Religious and cultural beliefs

• Reasoning and communication style

• Psychological diagnoses

• Mental states

• Medications

Main Components of Capacity

• The ability to understand the relevant information to make a treatment decision

• The ability to appreciate the importance of that information to one’s own situation, including risks and benefits of options

• The ability to reason about options consistently with one’s beliefs, values, etc.

• The ability to express a choice, either verbally or via another means

Assessing Capacity

• Attempt to maximize patient’s capacity

• Give time and reassess as needed and as can be allowed

Other Points to Consider

• Coercion

• Decision making structures– Culture– Family

• Personal History

If Determined Incapacitated

• Enter determination in medical chart including:– Nature– Etiology– Probable duration

• Inform and discuss with patient

• Talk to family/loved ones/surrogate

Resources

• Grisso T., Appelbaum P.S. Assessing Competence to Consent to Treatment: A Guide for Physicians and other Health Professionals. New York: Oxford University Press, 1998.

• New York Task Force on Life and Law. “Determining Incapacity.” http://www.health.state.ny.us/regulations/task_force/health_care_proxy/guidebook/