Assessment Of Decision-making Capacity Research Articles

Assessing decisionmaking capacity in a patient with nondominant hemispheric stroke.

Assessing decisionmaking capacity in a patient with nondominant hemispheric stroke.

Presumptions Respecting Mental Competence

This paper addresses the role(s) played by presumptions regarding mental competence in the context of clinical assessment of decision-making capacity. In particular, the issue of whether or not the usual common law presumption of competence is appropriate and applicable in cases of reassessment of persons previously found incompetent is discussed. Arguments can be made for either retaining a presumption of competence or adopting a presumption of incompetence in reassessment cases. In addressing the issue and the arguments, the authors conclude that the question is really a public policy issue which requires legislative resolution. In writing this paper, the authors have drawn on their joint clinical experience at the Baycrest Competency Clinic. Though the authors' jurisdiction is the province of Ontario, their intent is to raise awareness and to prompt consideration of this issue both inside and outside Ontario.

Evaluating Decisionmaking Capacity in the Elderly:

This article critically reviews and analyzes recent contributions to the medical and legal literature dealing with the subject of defining and assessing decisionmaking capacity in older patients/clients. The themes and issues set forth in this burgeoning literature are described and guideliens are commented upon in terms of their usefulness to practitioneres and the ethical and social policy implications they raise.

Assessing Treatment Decision‐Making Capacity in Elderly Nursing Home Residents

Clinicians usually employ indirect measures of cognitive and physical function in order to assess medical decision-making capacity. We tested a reference group of well elderly (Mini-Mental State Exam [MMSE] score = 29.1 +/- 0.8, mean +/- SD), for their understanding of three increasingly complex, hypothetical treatment situations or "vignettes"--use of a hypnotic, need for thoracocentesis, and desire for CPR. From this, we have developed a more direct, Guttman-like assessment of decision-making capacity. Of 51 Veterans Affairs nursing home residents (MMSE score = 22.4 +/- 6.9), only 33.3% demonstrated intact decision-making capacity by this method, whereas 77% were felt by their primary physicians to be capable of giving consent for oral surgery; 37.3% had very impaired decision-making capacity; and 29.4% were intermediate in this ability. Judged against our more direct assessment of decision-making capacity, primary physicians' judgment of capacity for consent was 31% to 39% sensitive in identifying impaired decision-making and the MMSE was 53% to 63% sensitive. These measures were 100% and 82% to 83% specific in identifying intact decision-making capacity, respectively. We conclude that (1) more directly assessed decision-making capacity varies noticeably among elderly nursing home residents and correlates in only limited fashion with frequently used cognitive screening methods; and (2) cognitive screening tests underestimate the prevalence of impaired decision-making capacity in this population. For informed consent and advance directives, our study suggests that decision-making capacity should be directly, rather than indirectly, assessed.

Ethical Aspects of Dementia

Dementia creates special ethical dilemmas and affects common ethical problems. In this article, the authors outline the clinical course of a demented patient in order to examine how different ethical issues tend to arise in different stages of dementia. The topics of accurate diagnosis, treatment planning (including advance directives), assessment of decision-making capacity, recognition of caregiver problems, and addressing end-of-life concerns are highlighted through the patient's case history. The setting of these ethical problems in the context of American society today and the special ethical issues in dementia research are also explored.

Riversin Practice: Clinicians' Assessments of Patients' Decision-Making Capacity

Since the Rivers v. Katz decision in 1986, clinicians in New York State have been required to assess patient decision-making capacity before judicial review of petitions to administer involuntary medication. The authors examined 42 capacity assessments made by psychiatrists at a large state hospital in New York City. Although the capacity assessments were often incomplete and rarely addressed the treatment decision, most clinicians judged patients as lacking capacity to make treatment decisions. The findings suggest that psychiatrists may view capacity assessments as irrelevant because of the manifestly grave nature of patients' illnesses or may not differentiate the capacity assessment from the mental status examination. The capacity assessment may nonetheless be a useful tool because it encourages clinicians to discuss the proposed treatment with patients and to present information more effectively in court.