A couple of years ago, I was asked to see Mr M, a 75-year-old patient with dementia, to help him and his family determine the goals of his medical care. He had a medical history significant for diabetes mellitus and peripheral vascular disease and had been admitted with a gangrenous foot. His physicians recommended amputation, but the patient refused. The patient's family believed that Mr M's dementia was affecting his decision and insisted that an amputation be performed despite the patient's wishes. When I interviewed the patient, it was apparent that he thought the year was 1964. However, it likewise became clear that even though he had some cognitive impairment from his dementia, he clearly did not want his leg amputated despite his family's insistence.
How, then, should physicians navigate such a conflict? Before considering a surrogate decisionmaker, one must first determine the patient's capacity to make medical decisions: the basis of the concept with which we are all familiar—informed consent. How then does one determine a patient's capacity to make medical decisions about his or her care?
Although sometimes a challenging task, any physician can determine a patient's decision-making capacity for a specific medical intervention. Unless a patient's decisions may be affected by mental illness (eg, depression, psychosis, etc), determination does not require psychiatric expertise. Quantitative measures of cognitive function, such as the mini-mental status examination, do not predict a patient's ability to make medical decisions. No formal practice guidelines exist to assess the capacity to make medical decisions, but structured assessment tools are available, such as the Aid to Capacity Evaluation (http://www.jointcentreforbioethics.ca/tools/ace.shtml).
Whether appropriate decision-making ability is determined using clinical assessment or a structured tool, several capacities have been deemed necessary aspects of decisionmaking. These decision-making capacities include the following:
1. Capacity to receive information and communicate a choice
• Can the patient hear or read?
• Can the patient speak or write?
• Does the patient require a translator?
2. Capacity to understand the relevant information
• “What is your understanding of your condition?”
• “What is the treatment being recommended to you?”
• “What other options have been presented to you by your physicians?”
3. Capacity to appreciate the situation and its consequences
• “What do you think will happen if you follow your physician's recommendations?”
• “What do you think will happen if you do not follow your physician's recommendations?”
• “What do you think will happen if we do nothing?”
4. Capacity to reason about treatment options
• Is the patient's decision affected by mental illness (eg, depression)?
• “Can you explain to me why you have made this decision?”
• “Can you explain to me what is most important to you now?”
With a careful assessment of each of these capacities, any physician may determine the medical decision-making ability of a patient for a particular medical intervention. Although at times a difficult task, assessing a patient's capacity to make medical decisions should be a part of every medical encounter and always must take place before concluding that an individual cannot speak for himself or herself. In the case of Mr M, clinicians determined that he retained capacity to make his own medical decisions. After a family conference during which he explained his rationale for declining amputation, his family agreed to follow his wishes.
- Academic Division of Ochsner Clinic Foundation
SELECTED READINGS
- Appelbaum PS. Clinical practice. Assessment of patients' competence to consent to treatment. N Engl J Med. 2007 Nov 1;357(18):1834-1840.
- Chow GV, Czarny MJ, Hughes MT, Carrese JA. CURVES: a mnemonic for determining medical decision-making capacity and providing emergency treatment in the acute setting. Chest. 2010 Feb;137(2):421-427.
- Etchells E, Sharpe G, Elliott C, Singer PA. Bioethics for clinicians: 3. Capacity. CMAJ. 1996 Sep 15;155(6):657-661.
- Jones RC, Holden T. A guide to assessing decision-making capacity. Cleve Clin J Med. 2004 Dec;71(12):971-975.
- Tunzi M. Can the patient decide? Evaluating patient capacity in practice. Am Fam Physician. 2001 Jul 15;64(2):299-306.
