Guardian or No Guardian: A Clinician’s Perspective on Capacity

Kyle S. Page, PhD, ABPP Geriatric Psychologist

Edward Hines, Jr. Veterans Affairs Hospital

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Disclaimer

• Views expressed in this presentation are my own and do not reflect official policy of the Department of Veterans Affairs

• No financial conflicts of interest or relationship with commercial products

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Outline

I. Brain Changes

II. A Clinician’s Evaluation

III. Increasing Support

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When the Brain Changes

What did your brain do to get you here today?

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Normal Brain Aging

• In practice, we can capture different “domains” or brain abilities with testing, such as:

– Language skills

– Reasoning abilities

– Attention / Concentration

– Memory

– Thinking speed

5

6

30

40

50

60

20 yrs old 40 yrs old 60 yrs old 80 yrs old

Vocabulary Reasoning Memory Speed

Based o

n S

althouse (

2010)

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Decision Making in Later Life

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Experience/ Background

Cognitive Shortcuts

Different Priorities

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The Clinical

Evaluation

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Recent Decisions?

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Using the Term “Capacity”

“an individual’s physical or mental ability; a legal status presumed to apply to all adults”

(American Bar Association and American Psychological Association, 2008)

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Historical Shifts

Clinical Judgment

Research and Standardization

Legal Reforms

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Capacity Myths

1. Capacity is “all or nothing”

2. Lack of capacity is permanent

3. Lack of one type of capacity means lack of the others

4. Only a specialist can decide

5. If they agree with the recommendations, they probably have capacity

(Ganzini et al., 2005)

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ABA/APA Framework

Legal Standard Functional Elements

Diagnoses

Cognitive Underpinnings

Psychiatric or Emotional Factors

Values

Risk Considerations

Steps to Enhance

Clinical Judgment

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The Basic Approach

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Clinical Interview Collateral Information

Standardized Cognitive Measures

Performance-Based / Capacity Assessments

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Components of Consent Capacity

I want to

discharge right

now!

Understanding Appreciation Reasoning Expressing

a Choice (Grisso & Appelbaum, 1998)

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Supporting the Individual

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Cognitive Change due to Disease

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Subjective Decline

Mild Cognitive Impairment

Major Neurocognitive

Disorder

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Other Influences on Decision Making

• Increasing Pain

• Decreasing Sleep

• Worsening Mood

• Temporarily Distracted

• Being Overwhelmed

• Medication Side Effects

• Mood Disorders

• Anxiety / Trauma

• Psychotic Disorders

• Education

• Health Literacy

• Lack of Inclusion

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Some Ways of Supporting

• Take time to repeat information

• Summaries / bullets of information (verbal and written)

• Deliver information through multiple methods

• Give time for person to process

• Review information again later (or at their best time)

• Share most important points at the end

• Involve others in process 19