Evaluation of medical decision making capacity in acute traumatic brain injury rehabilitation

Abstract

Concerns regarding medical decision-making capacity (MDC) occur during acute traumatic brain injury (TBI) rehabilitation. Although a majority of providers report MDC as a common concern, the level of training is inconsistent. This presentation provides an overview of MDC assessment and recommendations during acute TBI rehabilitation. MDC assessment involves a clinical interview, cognitive examination, and record review, although clinical practice varies. Clinical determination of MDC includes “has capacity”, “diminished capacity”, and “lacks capacity”. Four commonly adopted standards for determining MDC are: expressing a choice, understanding relevant information, appreciation of the situation and its consequences, and reasoning through the benefits and consequences of treatment options. While clinical judgment remains the “gold standard” for MDC assessment, instruments have been designed to enhance and support these evaluations. In acute TBI rehabilitation, evaluators should consider how TBI-related changes influence MDC. Appreciation of temporal changes in awareness and cognitive function might require assessment of MDC at multiple time points. Efforts to improve capacity, such as addressing communication barriers or treatment of delirium, might be necessary. Within the acute environment, providers have unique opportunities to assess and observe functional abilities on an inpatient service (e.g., psychology, speech therapy). Given the complexities of MDC assessment, potential “pitfalls” exist in determining MDC. Although MDC concerns are common among individuals during acute TBI rehabilitation, there is a dearth of MDC assessment training. While determination of MDC is based upon clinical judgment, instruments enhance MDC assessment. Given the complex dynamic nature of acute TBI rehabilitation, providers should be mindful that chronic and acute factors may influence evaluation of MDC. Awareness of MDC standards and TBI factors allow for more accurate assessment of MDC during acute rehabilitation.