Decision-making capacity evaluations: the role of neuropsychological assessment from a multidisciplinary perspective

Sarah Wood,Patrick Fassbind,Christine Cabane,Andreas Monsch,Klaus Bally,Ralf J Jox,Thomas Leyhe,Manuel Trachsel

doi:10.1186/s12877-020-01932-x

Abstract

Decision-making capacity (DMC) in aging adults has become increasingly salient as the number of older adults, life expectancy, and the amount of wealth to be transferred from older generations have all increased. The accurate and reliable determination of older adults’ DMC is a particularly important topic given its implication in legal, financial, and health decisions. Based upon the four-ability DMC model promulgated by Appelbaum and Grisso in the 1980’s, a number of MacArthur Competence Assessment Tools have been developed and widely utilized. However, these tools do not include cognitive testing or other sources of objective data and have limited validity in a medico-legal setting, necessitating additional options for the evaluation of DMC. This is significant from the perspective of the patient because they have a vested interest in accurate and objective assessment of their DMC across domains.Given the disparities in the assessment of DMC, the authors propose, through this debate article, that the evaluation of DMC in the aging adult population utilize a combination of traditional interview and domain specific instruments and neuropsychological testing. To achieve a consensus on the issue, medical experts in a number of fields related to capacity evaluation, including psychiatry, neurology, neuropsychology, and general medicine were consulted and recruited as authors. Experts in Swiss law and ethics were also consulted and provided input.A tendency to focus on a single capacity, and in particular, the ability to consent to medical treatment, arose in the literature. Similarly, there are many instruments purporting to evaluate a single capacity (e.g., consenting to medical treatment, managing finances), while other areas important to the evaluation of DMC received little attention (e.g., activities of daily living, the ability to live independently, to marry, to resist undue influence, and to make a will or advanced care directive). Medical and legal experts in the multidisciplinary group agreed that there is a clear need for more consistency across evaluation of DMC domains and that a combined approach of traditional methods and neuropsychological testing provides a more thorough evaluation and better serves the patient.

Highlights

The issue of Decision-making capacity (DMC) evaluation has become increasingly relevant and will continue to gain importance as the world’s aging population and the number of people with dementia both increase
With respect to specific DMCs, we found in a review of recent literature that the DMC to consent to medical treatment received the greatest attention
Utility and discussion The authors propose using a combination of traditional DMC assessment methods typically utilized by primary care physicians and attorneys, such as interviews and tools designed for specific capacities, with neuropsychological evaluation

Summary

Introduction

The issue of DMC evaluation has become increasingly relevant and will continue to gain importance as the world’s aging population and the number of people with dementia both increase. There are limited standardized means for clinicians to evaluate an individual’s capacity to make important life decisions such as executing a will, consenting to medical treatment, or engaging in financial or highly personal contracts.

Results

Conclusion