UMMS CRIT Module I: Understanding Decision-Making Capacity Gary Blanchard, MD Division of Geriatric Medicine UMMS

UMMS CRIT Module I: Understanding Decision-Making Capacity

Gary Blanchard, MDDivision of Geriatric Medicine UMMS

UMMS CRIT 2012 Module I: Understanding Decision-Making Capacity

Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation

• Upon completion of this lecture, the participants will be able to:

– Explain the principles of decision-making capacity.

– Recognize that no disease – including dementia –

automatically negates decision-making capacity.

– Identify common misconceptions about capacity.

– Apply the principles of capacity assessment in their daily

clinical encounters.

Objectives



Retrieved April 20, 2010 from http://artfiles.art.com/5/p/LRG/22/2207/5VAAD00Z/norman-rockwell-doctor-and-the-doll.jpg

Paternalism



Patients have the right to

make what we consider

to be “bad” decisions,

including refusing

treatment that we think is

in their best interest.

Patient Autonomy



We as physicians must feel that a patient

has the capacity to make that

specific decision …

But there’s a catch …



Retrieved April 16, 2010 from http://www.homeownershiprevolution.com/images/Here%20Comes%20The%20Judge.jpg

Retrieved April 16, 2010 from http://ts1.mm.bing.net/images/thumbnail.aspx?q=1627325924800&id=9a0c12d9f878bf67bd5adf96fec7bb15&url=http%3a%2f%2fwww.facebook.com%2fprofile%2fpic.php%3foid%3dAAAAAQAQOYY-wNCuQPKRrJ0oI1M69wAAAA8_c3DwT6DY-1jOtMaUKFMI

Capacity vs. Competence

http://www.homeownershiprevolution.com/images/Here%20Comes%20The%20Judge.jpg





Retrieved April 16, 2010 from http://online.wsj.com/media/scales_art_160_20080808131250.jpg

Decision-Making Capacity

• Ideally, balance the respect for

a patient’s autonomy with

protecting a vulnerable patient

from the consequences of a

bad decision.

• No clear guidelines – clinical,

legal, and ethical

considerations



– Expresses appreciation of the situation

– Understands consequences of the decision

– Manipulates information

– Reasons coherently

– Able to paraphrase

Standard of Informed Consent



• In general, we only think of the notion of

capacity when someone disagrees with our

treatment plan.

• Literature suggest that 40-50% of medical

patients admitted to the hospital lack decision-

making capacity(!).

We Don’t Think Of It Enough …



• Vast majority of people possess capacity

• Decision-specific (medical, financial, housing) –

not all of nothing … and may fluctuate!

• Standard proportional to risk (“sliding scale”)

– High Risk – High Standard

– Low Risk – Low Standard

Pearls/Guiding Principles



• No disease alone – like dementia –

automatically negates decision-making capacity.

• No magic MMSE number (also important to

remember shortcomings of MMSE)

• A patient may continually forget the facts of

their condition – but can they express their

values when you repeat the scenario to them?

Who Lacks Capacity?



• History (medical, psychiatric, social)

• Cognitive testing

• Functional assessment

• Assess a patient’s values and goals of care

Evaluating Capacity



1. Communicate a choice

2. Understand the relevant information

3. Appreciate the situation and its consequences

4. Reason about treatment options

Core Principles

Unfortunately, no one useful, validated tool for assessing capacity currently exists.

Appelbaum, P.S. (2007). Assessment of patients’ competence to consent to treatment. New England Journal of Medicine, 357 (18). 1834-1840.



• Clearly indicate preferred treatment option

–“Have you decided whether to follow your doctor’s

recommendation for treatment?”

–“Can you tell me what that decision is?”

–“What is making it hard you for to decide?”

Communicate a Choice



• Grasp the fundamental meaning of information communicated by physician

“Please tell me in your own words what your doctor told you about …• the problem with your health now• the recommended treatment• the possible benefits and risks of the treatment and any

alternatives.

Understand the Relevant Information



• Acknowledge medical condition and likely consequences of

treatment options

– “What do you believe is wrong with your health now?”

– “What do you believe will happen if you are not treated?”

– “Why do you think your doctor has recommended this

treatment?”

Appreciate the Situation and Its Consequences



• Engage in a rational process of manipulating the relevant

information

– “How did you decide to accept or reject the recommended

treatment?”

– “What makes [chosen option] better than [alternative

option]?”

Reason about Treatment Options



Surrogate Decision-Making

• Reflects self-determination and Western notion of personhood,

especially pronounced in the United States (bioethical

hierarchy):

– Patient (who possesses decision-making capacity)

– Patient’s Known Wishes

– Substituted Judgments

– Patient’s Best Interests



• Massachusetts Health Care Proxy Law

• Legal Guardian

• Section 12

Massachusetts rules



THE SIMPSONS. Dr. Nick Riviera on THE SIMPSONS on FOX.

2002T��HE SIMPSONS and TTCFFC ALL RIGHTS RESERVED

2002F��OX BROADCASTING CR:FOX

Take Home

As a physician, there is no greater responsibility you possess than assessing your patient’s decision-making capacity.



Lessons Learned

Documents

UMMS CRIT Module I: Understanding Decision-Making Capacity Gary Blanchard, MD Division of Geriatric Medicine UMMS