Decision-Making Capacity WorkshopMarch 07, 2020 20 / 20

on capacity!

Presenter: Lesley Charles, MBChB, CCFP(COE)• Speakers Bureau/Honoraria: Workshop Participant Fee - FMF

• Consulting Fees: N/A

• Grants/Research Support: N/A

• Patents: N/A

• Other: N/A

• The Alberta College of Family Physicians has provided support in the form of a speaker fee and/or expenses.

•Learning Objectives

1. Identify when to initiate a capacity assessment2. Describe tools that should be used in a standardized approach when

conducting a capacity assessment3. Select which forms need to be completed for a capacity assessment4. Outline the legal implications/framework surrounding the documentation

Mrs C

• 59 yo lady with early onset dementia

• Lives with husband and supported by 2 kids

• Longstanding abuse both verbal and physical

• Contact by HC after an episode of physical abuse involving RCMP.

They feel Mrs C should have a capacity assessment and be placed.

• Mrs C want to stay home

What would you do?A. Complete DMCA as requested.

B. Involve Elder Abuse team.

C. Admit to hospital.

D. Gather more information.

Background

• A person’s capacity to make personal/financial decisions is an important component of independence

• Adults with developmental disabilities, psychiatric, and cognitive disorders can face challenges to their autonomy.

• As the prevalence of persons 65 years and older rises, so does the incidence of dementia.

• It is anticipated that increasing numbers of individuals will experience a decline in their DMC.

WHO• The World Health Organization (WHO) states that legislation should:

• “recognize and protect the right to appropriate autonomy and self-

determination,”

• and ensure “free and informed consent to treatment, supported

decision-making, and procedures for implementing advance

directives.”

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Capacity DefinitionThe ability to understand the

information that is relevant to making of a personal decision and

the ability to appreciate the

reasonable foreseeable consequences of the decision.

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Risk by Choice

• A risky decision is not necessarily an incompetent decision.

• Stockbrokers, soldiers, medical professionals and patients make them every day.

• It is the process – or the lack of process – by which risky decisions are made that calls into question the capacity of a patient to make that decision.

Decision-Making Capacity can affect anyone…

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Relevant Legislative Acts – Alberta Example• Personal Directives Act

Allows adult Albertans to create a Personal Directive to name people (agent) to make decisions and describes areas in which they want decisions made for them

• Powers of Attorney ActAllows adult Albertans to create an Enduring Power of Attorney to name people (attorney) to make decisions in financial matters for them

• Adult Guardianship and Trusteeship Act • Continuum of Decision–making

• Legal process for granting powers of surrogate decision making

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Personal Directive Act

• Schedules

• A process for determining incapacity

• Expanded scope of Service Providers in healthcare such as Registered Nurses, Psychiatric Nurses, SW, OT to act as the second signature

• Allow for re-assessment of capacity or determination of regained capacity

• Complaints process via OPG (similarly under AGTA)

• Tailored to different levels of capacity

• Designed to provide as much autonomy as possible

AGTA has multiple decision-making options.

Specific Decision-Making

and Emergency Decision-

Making

SupportedDecision-making

Authorization

Guardianship,

Trusteeship and

Protection

Temporary Guardianship/

TrusteeshipAdult Makes

Decisions

Co-Decision-

Making

Range of Capacity

Has Capacity Significant

Capacity

Impairment

Temporary lack

of Capacity

Lacks Capacity

Long Term

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Decision-Making Capacity Process - 3 Stages

YESAre concerns

valid?

ScreeningIdentify Triggers for

Questioning Capacity,Domains and Risks

Problem SolvingUse Team Approach –

Cognitive/Functional Tests, Options to Reduce Risk

Capacity InterviewProceed when Risks not

resolved by Less Intrusiveor Restrictive Means

YESDecision Making Called into

Question

Collect Information and Identify

Relevant Domains

Address Medical/

PsychiatricProblems

Perform Cognitive/ Functional

Assessments as needed

Consult/Meet with

Other Team Members to

Problem-solve

Proceed with

Capacity Interview

NOProblem Solved?

NO

Assess-ment

Done &Problem Solved?

Refer to: Geriatricians, Psychologists,

DCAs, as Appropriate

Proceed with Appropriate

Forms

Education/Support Provided by Mentoring Team

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Validating Reasons and Identifying Domains

YESAre concerns

valid?

Decision Making

Called into Question

Collect Information and Identify

Relevant Domains

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Valid Reasons for Assessment

A formal capacity assessment may be necessary if the reason for assessment meets the following criteria:

1. An event or circumstance which potentially places a patient, or others, at risk that

2. seems to be caused by impaired decision-making which

3. Necessitates investigation, problem-solving (and possibly action) on the part of a health care professional

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Domains of Decision-Making

Health care Participation in social activities

Accommodation Participation in educational activities

With whom to live &

associate

Participation in employment

activities

Legal matters Financial and Estate

Identifying Domains

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Care Map – Assessments & Problem Solving

ProblemSolved?

Address Medical/

PsychiatricProblems

Perform Cognitive/ Functional

Assessments as needed

Consult/Meet with

Other Team Members to

Problem-solve

How to Proceed?

• Treat acute medical issues, especially those affecting cognition

• Involve the interdisciplinary team for functional assessments; ask SW to initiate the Capacity Assessment Process Worksheet

• Thoroughly identify risks and investigate risk reduction measures

• Focus on problem-solving the patient’s issues without resorting to capacity assessment

“Form 1”: Capacity Assessment Process Worksheet: Datagroup # 09947

• Standardized form that ensures teams follow the Capacity Assessment Process.

• Allows teams to gather and document relevant information regarding:

• risk-factors

• areas of decision-making that are in question

• Attempts at problem solving/intervention, including education, formal/informal supports

• Assists in determining if a formal capacity interview is needed.

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Capacity Assessment

Process Worksheet

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Cognitive Testing

Types of tests used:

• MMSE

• MOCA

• Cognistat

• EXIT/FAB

• Kitchen Task Assessment

• ILS

• Psychological Testing

Testing Limitations

• Level of consciousness

• Education

• Cultural background

• Language

• Vision

• Hearing

• Comorbidities (aphasia, delirium, depression)

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Cognitive Assessment

• There is no cognitive test that will determine capacity

• Assessment of a person’s cognition is not necessarily equivalent to their abilities

• Not solely used to determine one’s capacity for decision making.

A Word on Problem-solving

• Be creative !!

• Involve patients and families in problem-solving

• Seek perspectives from other team members

• Consider formal resources

• Mobilize informal resources

• Issue may be resolved by problem solving without formal capacity assessment

Complex situations unlikely to benefit from CA

• Driving

• Refusal to take medications

• Where agent/guardian will respect patient’s wishes e.g. to stay home at risk

• Longstanding choices that pose risk, e.g. ETOH, Drugs –will depend on development of cognitive impairment

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“Form 2”: Reasons to Proceed to Formal Capacity Interview: Datagroup # 09948

• No adequate solutions from problem-solving

• Risk to patient / others too high

• Other, less intrusive methods, have failed

• Appointment of legal decision-maker may solve the problem

• Problem persists or becomes worse

• Remember: a determination of incapacity may do nothing to fix the problem

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Capacity Interview

Worksheet

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Care Map – Capacity Interview

AssessmentDone &Problem Solved?

Proceed with Capacity Interview

Refer to: Geriatricians, Psychologists,

DCAs, as Appropriate

NO

YES

Proceed with Appropriate

Forms

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Anatomy of a Capable Decision – The 3 Cs

• The decision-maker is aware of the problem (context), and choices that are available.

• The decision-maker understands the reasonably foreseeable effects or consequences of each choice.

• The decision-maker makes a choice after weighing the relative benefits and disadvantages of the choices available.

“Form 3”: Paperwork after finding Patient Incapable

• Depends on 2 factors:

− on which domain assessed

− Paper work patient has

• Basically 3 options:

− Schedules under PDA

− CAR under AGTA different forms depending on is applying for CDM, guardianship/trusteeship, SDM

− Enactment for EPOA – no formal template

Mrs C

• 59 yo lady with early onset dementia

• Lives with husband and supported by 2 kids

• Longstanding abuse both verbal and physical

• Contact by HC after an episode of physical abuse involving RCMP. They feel Mrs C should have a capacity assessment and be placed.

• Mrs C want to stay home

What would you do?

A. Complete DMCA as requested

B. Involve Elder Abuse team

C. Admit to hospital

D. Gather more information

Liability• The Personal Directives Act state that

• …an agent or a service provider is not liable for what they do or omit to do,

• ….as long as they are acting in good faith and in accordance with the Act.

Fees guideline for DCA (physicians not bound)

• s. 9 AGTR - fees for court applications for single appointments and section 96 assessments: up to $500

• For court applications for dual (G and T) appointments: up to $700

• Court, on application, may set a higher fee based on complexity of assessment, but not when Minister pays for assessment

Billing

• 03.04N Comprehensive evaluation including completion of forms to determine capacity as defined by the Personal Directives Act (PDA) (RSA 2007 s9(2)(a)) 182.59

Note: 1. Benefit includes witnessing the agents' or service providers‘ assessment.

2. May be claimed to determine lack of capacity or to determine that capacity has been regained.

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DMCA Model

• In summary, the decision-making capacity assessment Model was developed in Alberta and aligned with provincial legislation.

• It outlines DMCA best practices and includes

− a care map.

− worksheets.

− staff training workshops.

− Physician training workshops.

− Grand rounds/ Educational sessions.

• It has been used by physicians and other health care professionals across the care continuum.

DMCA Education

• 3-4 hour workshop and refreshers for healthcare professionals

offered via Covenant Health, AHS, Bethany Care Society and Good Samaritans Society

• 3-hour level 1 workshop for physicians (accredited by the CFPC for 6

Group learning credits)

• 3-hour level 2 workshop for physicians (accredited by the CFPC for 6 Group learning credits)

• 2-day workshop for physicians via OPGT

Resources for Healthcare Providers

• Office of the Public Guardian and Trustee:Help for Incapable adults homepage https://www.alberta.ca/help-incapable-adults.aspx

• AHS - Adult Guardian &Trustee Act: Resources https://www.albertahealthservices.ca/info/Page853.aspx

• Covenant Health - Capacity Assessment Resourceshttps://medicalstaff.covenanthealth.ca/clinical-supportservices/capacity-assessment

• AHS- Capacity Assessment Resourceshttps://insite.albertahealthservices.ca/assets/ppc/tms-ppc-social-work-decision-making-toolkit.pdf

Contact Information

Lesley Charles, MBChB, CCFP COEAssociate Professor & Program Director

Division of Care of the ElderlyDepartment of Family Medicine

University of AlbertaLesley.Charles@albertahealthservices.ca

Questions