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decision-making capacity; decisional capacity

Ability to adequately participate in medical decisions. Clinical significance: - decisional capacity of the patient to make informed decisions - 1st step in obtaining informed consent [11] - dementia & psychiatric illness may interfere with a patient's ability to make informed decisions regarding medical treatment, self-care or issues such as finances - decisional capacity is decision-specific Notes: 1) requirements a) able to understand relevant information b) ability to appreciate the situation & its consequences c) able to rationally manipulate information (reasoning) d) able to communicate choice & reason(s) for choice 2) capacity may be gained or lost, requiring re-evaluation; clinical maneuvers may enhance capacity a) depression: pharmaceuticals, psychotherapy b) delirium: treat underlying disorder c) psychosis: pharmaceuticals d) cultural mismatch: seek culturally competent communication style 3) capacity may be decision-specific, i.e. decisions which entail a greater risk of harm may require stricter standards for capacity 4) geriatricians have the ability to determine decision-making capacity in most cases a) either psychiatry &/or neurology input is sometimes helpful b) any physician can determine if a patient has decision-making capacity [3] 5) minors who are not living independently of parents, not married, & not in the armed forces cannot legally make their own medical decisions [3] 6) if a patient is incapable of decision-making capacity a) a surrogate decision maker is identified b) the surrogate makes medical decisions for the patient 1] substituted judgement: - the decision the surrogate believes the patient would have made 2] best interest: - the decision the surrogate believes best for the patient [3] 7) competence is a legal term

Related

advance directives autonomy competency decision making medical ethics

Specific

assessment of decisional capacity

General

capacity

References

  1. Rosenfeld K. In: Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 2001
  2. Rosenfeld K. In: Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 25-28, 2002
  3. Medical Knowledge Self Assessment Program (MKSAP) 14, 17. American College of Physicians, Philadelphia 2006, 2015
  4. Assessment of Decisional Capacity and Competency, Drickamer MA, Chapter 10, In: Principles of Geriatric Medicine and Gerontology, 5th edition, Hazzard WR (ed)
  5. Decision Making, Kapp M & Funaucance T, Chapter 24, Comprehensive Geriatric Assessment, Osterweil et al eds, McGraw Hill, New York, 2000
  6. Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013 - Geriatric Review Syllabus, 9th edition (GRS9) Medinal-Walpole A, Pacala JT, Porter JF (eds) American Geriatrics Society, 2016
  7. Sessums LL, Zembrzuska H, Jackson JL. Does this patient have medical decision-making capacity? JAMA. 2011 Jul 27;306(4):420-7 PMID: 21791691
  8. Appelbaum PS. Clinical practice. Assessment of patients' competence to consent to treatment. N Engl J Med. 2007 Nov 1;357(18):1834-40. PMID: 17978292
  9. Simon JR. Refusal of care: the physician-patient relationship and decisionmaking capacity. Ann Emerg Med. 2007 Oct;50(4):456-61. Epub 2007 Jun 20. PMID: 17583381
  10. Leo RJ. Competency and the Capacity to Make Treatment Decisions: A Primer for Primary Care Physicians. Prim Care Companion J Clin Psychiatry. 1999 Oct;1(5):131-141. PMID: 15014674 Free PMC Article
  11. Hall DE, Prochazka AV, Fink AS. Informed consent for clinical treatment. CMAJ 2012 184(5):533-540 PMID: 22392947 PMCID: PMC3307558 Free PMC article