Decision Making Capacity

1
Decision Making Capacity

• Adapted from a presentation by Arthur R. Derse
  MD, JD, FACEP

2
Decision Making Capacity

• Ability to make decisions about medical care
• vs. competence

3
Decision Making Capacity

• Understands information
• Reasons and deliberates about choice
• Makes a choice consistent with values and goals
• Communicates a choice
• Stability of choice over time

4
Decision Making Capacity

• Questions of patient capacity in decision making
  typically arise only when a patient chooses a
  course -- often refusal of treatment -- other
  than the one the health professional finds most
  reasonable.
• Roth LH, Meisel A, Lidz CS. Tests of competency
  to consent to treatment. 134 Am J Psychiatry
  1997134279.

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Decision Making CapacityDetermination

• Individual abilities of patient
• Requirements of task
• Consequences of decision
• When the consequences are substantial, greater
  need for certainty of capacity
• Presidents Commission 1982

6
Decision Making CapacityNot necessarily
established by

• Simply expressing a preference
• Content of patient decision objectively correct
  standard
• Concurrence with recommendations
• Presidents Commission 1982

7
Obvious Incapacity

• infants
• young children
• comatose
• severely mentally handicapped
• Presidents Commission 1982

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Decision Making CapacityRole of Mental Status
Exam

• Mini Mental State - orientation, memory,
  attention, reasoning ability
• May not address critical issues of capacity
• Patients with abnormal mental status may be found
  decisional
• In re Quackenbush 1978
• Role of mental health professionals

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? Irrational Choices

• Bias toward the present and near future
• Unrealistic attitudes toward risk
• Fear of pain or medical experience
• Framing effects - Losses loom larger than gains
• Brock DW, Wartman SA. When competent patients
  make irrational choices. NEJM 19903221595-99.

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Choices and Context

• Religious beliefs
• Wons 1987, Fosmire 1990
• Cultural attitudes

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Decision Making for Incapacitated patients

• Guardian
• Agent - Power of Atty for Health Care
• Other surrogates
• Standards
• Best interest
• Substituted judgment