The capacity to determine capacity

One in four medical inpatients can't make a decision. And not just about whether to have the chocolate or vanilla pudding for dessert.

One in four medical inpatients can't make a decision. And not just about whether to have the chocolate or vanilla pudding for dessert.

A recent review of research on medical decision making found that 26% of hospital patients lacked the capacity to decide about their own care. Adding to the problem, only 42% of incapable patients were recognized by physicians as such.

Photo by Thinkstock
Photo by Thinkstock.

“We were surprised about the prevalence of incapacity,” said Laura Sessums, MD, JD, FACP, lead author of the review, which was published in the July 27 Journal of the American Medical Association. “Knowing that a quarter of your patients are potentially lacking medical decision-making capacity is a really important piece of information.”

As the review's findings on physicians showed, another key piece is identifying these patients. “In many instances it doesn't take a psychiatrist to evaluate for capacity. Any physician should know the basics of how to do this,” said Laura Dunn, MD, associate professor and director of psycho-oncology at the University of California, San Francisco (UCSF).

The basics are best learned in school or training (“That's one of our next missions, to try to address a deficiency in education,” said Dr. Dunn). But experts in the field did have some tips to help hospitalists already in practice spot patients with potential capacity issues, screen them effectively, and know when to call for backup.

Notice the problem

The first common obstacle is unawareness of the importance of deliberate screening. “There's a fair amount of data that suggests that physicians often make judgments about patients' decision-making capacity based on global impressions, rather than specific examination of the relevant function,” said Paul S. Appelbaum, MD, professor of psychiatry, medicine and law at Columbia University College of Physicians and Surgeons in New York.

Such casual assessments can be misleading, according to Dr. Sessums, who is an internist at the Walter Reed National Military Medical Center in Bethesda, Md. “Patients' social skills are often preserved even when other abilities are lost. In a more superficial or brief interaction, the findings are subtle, so physicians might be less likely to recognize them,” she said.

The best way to avoid that pitfall is to spend a little of a resource that's precious to every physician—time. “Everyone is busy, but once you recognize that capacity is a potential issue, the best way to start the assessment is to pull up a chair and set aside 15 minutes and have a proper chat,” said Edward Etchells, MD, associate professor in the department of medicine at the University of Toronto. “There's no lab test; there's no CT scan that's going to do that for you.”

There are, however, some tests that can help with the assessment process. Dr. Etchells developed the Aid to Capacity Evaluation (ACE) and Dr. Appelbaum created the MacArthur Competence Assessment Tool for Treatment, both of which have been validated by research.

Cognitive status assessments, such as the Mini-Mental State Examination, can be useful in these situations too. “Not because cognitive status tests are the right way to do a capacity assessment, but they provide useful supportive data,” said Dr. Etchells. “You cannot say that a patient is incapable simply because they got a score of 15 out of 30 on a Mini-Mental State Examination, but that score in conjunction with an ACE interview and a documentation of the results of that interview is good evidence.”

The big four

While assessment aids can be helpful, experts said physicians can also tackle these evaluations all on their own as long as they know to cover the four basic components of decision making: understanding, appreciation, reasoning, and choice.

When a patient's understanding of his medical condition is in question, the first step is to explain the problem to him as clearly as possible, multiple times if necessary. “If I go to a patient and say, ‘Mr. Smith, what is your understanding of your current medical condition?’ and Mr. Smith says, ‘I have no idea,’ there are two possibilities. One is that Mr. Smith truly lacks the capacity to understand, but the more common reason is that no one's actually explained it to him properly,” said Dr. Etchells.

The patient's understanding of the clinical issue doesn't have to be perfect. “If they're refusing treatment, you want to know that they understand the risk of refusing treatment, like the infection could spread and they could die. But they don't have to understand the mechanism,” said Dr. Dunn.

Assessing a patient's understanding of his or her condition and appreciation of the risks and benefits of treatment can be tricky, she noted. “Sometimes people can parrot back to you what you told them, but when you probe further they seem to lack a little bit of deeper appreciation.”

The degree of understanding and appreciation that's required may also vary depending on the decision at hand. “I may be much more inclined to give that patient the benefit of the doubt, everything else being equal, if it's a fairly modest, low-risk skin surgery than if it's cardiac angioplasty,” said Daniel C. Marson, JD, PhD, professor of neurology at the University of Alabama at Birmingham.

Physicians should also consider the consequences of the evaluation itself, said Jewel Shim, MD, associate clinical professor of psychiatry and director of consultation liaison services at UCSF. “Say this person doesn't have capacity, then what lengths is the physician prepared to go to enforce treatment against the patient's will? If it's a case that the patient doesn't want a feeding tube or to wear oxygen, they they'd have to restrain the patient. In some cases, the physician will re-evaluate how necessary the treatment is.”

Physicians should look carefully at the reasons for the patient's decision, as well. “Reasoning is not the same as reasonableness. I think that's often where physicians get hung up. It's really difficult when somebody makes what we think is a really bad decision,” said Dr. Dunn. Although a bad decision is often the trigger for a capacity assessment, it's not proof of incapacity, she added. “They can make bad decisions, as long as they can explain their reasoning.”

A thorough conversation about the patient's reasoning can sometimes uncover underlying issues that may be more easily resolved than incapacity. “Maybe the patient is terrified and nobody's asked, ‘What are your concerns?’” said Dr. Dunn.

Medications can also create the appearance of incapacity. “Identify any potentially reversible factors,” advised Dr. Etchells. “For example, if the patient received a sedating drug the night before, maybe they'll do better on the capacity assessment and the cognitive status assessment if you stop that drug and talk to them tomorrow.”

In such situations, it's important to know the qualifier on the final category: choice. Patients must express “a choice that's stable over time,” said Dr. Dunn. Therefore, it may be necessary to revisit the issue in borderline cases. “The best way to address uncertainty is to repeat the dialogue the next day and see if you're getting consistent performance,” said Dr. Etchells.

Expert backup

Of course, another solution to uncertainty is to call an expert, usually a consultant psychologist or psychiatrist. “If after several attempts to assess capacity [physicians] have been unsuccessful, that would be a time they would consider asking for further help,” said Dr. Shim.

Many physicians call for help before that point, however. “There's a little bit of a misconception that psychiatrists are required to weigh in on capacity, when in fact it's any physician that can do so,” said Dr. Shim.

Calling for a consult can actually consume more of both hospitalists' and psych experts' time, Dr. Etchells noted. “The first thing they're going to do is say, ‘OK, you come with me to the bedside and I'm going to watch you explain what's wrong with this patient to them,’” he said.

“Having an outside person come in introduces noise into the system,” added Dr. Dunn. “[Hospitalists] should view themselves as the first line of assessment. If they get stuck or need some help, or if it seems like there are psychiatric issues, then they really should call psychiatry.”

If an internist doesn't feel experienced or trained enough to be the first-line assessor (“You wouldn't want somebody to read about doing a lumbar puncture in a book and then go try one,” Dr. Appelbaum said), hospital psychiatrists can also be an educational resource.

“The next time, go ahead and call psychiatry and say, ‘Hey, can you walk me through this? Can I watch so I can see how you do this because I really want to learn from you so that I can try and do these assessments more myself?’” suggested Dr. Dunn. “The psychiatrists will love that.”

Hospitalists might love it too, when they find that assessment is a skill that they can learn and perform successfully. Dr. Marson conducted two studies in which physicians were asked to judge the capacity of patients with mild Alzheimer's disease. In the first, the doctors were given no assistance and their assessments were highly inconsistent. “One physician thought that almost all of them were incompetent and another physician that they were almost all competent,” he said. “It was kind of a worrisome finding.”

But then the researchers tried the test again, and this time helped the physicians out by breaking the interviews down into the four categories of understanding, appreciation, reasoning and choice. “There were high levels of agreement,” Dr. Marson said. “The beauty of that study is that it shows that systematic training in this area will enhance judgment reliability.”