Capacity Determination

May 7th, 2008

Alan Sanders, Ph.D.Director, Center for Ethics

Saint Joseph’s Health SystemSystem Ethicist, Catholic Health East

Etiquette • Press * 6 to mute;

• Press # 6 to unmute

• Keep your phone on mute unless you are dialoging with the presenter

• Never place phone on hold

• If you do not want to be called on please check the red mood button on the lower left of screen

Overview

• The foundations of capacity determination

• Delineation of decision-making capacity for healthcare

• The main components of decision-making capacity

• Assessing decision-making capacity

Illustrative Case

• Mary is a 48 year-old married mother of two with frequent admissions to the hospital over the last few years with cardiac, pulmonary, and gastrointestinal issues. She is also bi-polar and has a history of alcoholism. Numerous times clinicians have documented her as a “failure to thrive”. The clinician recommends a colonoscopy to help determine the cause of her gastrointestinal issues. Mary refuses saying she has been poked and prodded enough times. If it is her time to go, it is her time to go.

The Foundations of Capacity Determination

• Respect for Human Dignity– Protection– Right to accept or refuse treatment

• Principle of Subsidiarity– Participation in the process

Delineation of Capacity

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

• Patients are presumed to have capacity unless they demonstrate otherwise

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

• Decision specific

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

• Assess the patient’s four main abilities

• Attempt to maximize patient’s capacity

• Give time and reassess

Questions to Consider• Does the patient understand what is wrong and what the

proposed treatments are?

• Does the patient understand the benefits and risks of difference proposed treatments or no treatment?

• Can the patient reason about the medical information and relate this information to his or her personal values? – Is this reasoning consistent over time and with their

values?

• Can the patient communicate in some fashion why he or she has made a certain decision?

Questions to Consider

• How has the diagnosis affect you, personally, spiritually?

• What reasons are important to you in accepting or refusing treatment?

• What are your sources of strength, such as loved ones, friends, or faith, and how have these influenced your decision?

Factors the Influence Assessment

• Religious and cultural beliefs

• Reasoning and communication style

• Disagree with physician

• Appearance

• They’re crazy!

Factors that Might Trigger an Assessment

• Refuse routine or life sustaining treatment

• Psychological Issues

• Consent to questionable/very risky procedures

• Diagnosis

• Medications

Determined Incapacitated

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

• Inform and discuss with patient

• Talk to family/loved ones/surrogate

Other Points to Consider

• Coercion

• Decision making structures– Culture– Family

• Minors

Illustrative Case

• Mary is a 48 year-old married mother of two with frequent admissions to the hospital over the last few years with cardiac, pulmonary, and gastrointestinal issues. She is also bi-polar and has a history of alcoholism. Numerous times clinicians have documented her as a “failure to thrive”. The clinician recommends a colonoscopy to help determine the cause of her gastrointestinal issues. Mary refuses saying she has been poked and prodded enough times. If it is her time to go, it is her time to go.

Resources

• Grisso T., Appelbaum P.S. Assessing Capacity 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/