Can the Patient Decide? Evaluating Patient …

1 Can the Patient decide ? Evaluating Patient Capacity in Practice MARC TUNZI, , Natividad Medical Center, Salinas, California Physicians assess the decision-making capacity of their patients at every clinical encounter. patients with an abrupt change in mental status, who refuse recommended treatment, who consent too hastily to treatment or who have a known risk factor for impaired decision-mak- ing should be evaluated more carefully. In addition to performing a mental status examina- tion (along with a physical examination and laboratory evaluation, if needed), four specific abilities should be assessed: the ability to understand information about treatment; the abil- ity to appreciate how that information applies to their situation; the ability to reason with that information; and the ability to make a choice and express it.

2 By using a directed clinical interview or a formal capacity assessment tool , primary care physicians are able to perform these evaluations in most cases. (Am Fam Physician 2001;64:299-306.). A. ssessing a Patient 's medical deci- computed tomography (CT) scan showing a sion-making capacity is part of pancreatic lesion that may be the primary every medical encounter. The cancer and is the only lesion accessible for process is generally spontaneous biopsy. He requires large doses of narcotics and straightforward: during the for pain control and his level of consciousness performance of routine inpatient and outpatient fluctuates greatly.

3 It is not clear if he under- visits, physicians confirm the ability of their stands his prognosis or that a tissue diagnosis adult patients to understand their medical con- will probably not affect treatment or out- dition and options for care. For some patients , come. When he is more lucid, he wants the however, the assessment may not be straightfor- test a CT-guided pancreas biopsy. Does ward. Consider the cases presented below. this Patient have the capacity to consent to this procedure? Illustrative Cases CASE 1 When to Assess Capacity A 54-year-old woman with diabetes and Four clinical scenarios are described1 that schizophrenia has been hospitalized with should alert physicians to assess a Patient 's unstable angina, bilateral heel ulcers, urinary decision-making capacity more carefully than retention caused by an acute urinary tract usual.

4 The first occurs when patients have an infection and anemia caused by a combina- abrupt change in mental status. This change tion of gastritis and chronic renal failure. One may be caused by hypoxia, infection, medica- year ago, she was hospitalized with diabetic tion, metabolic disturbances, an acute neuro- ketoacidosis after reporting that voices told logic or psychiatric process, or other medical her to stop taking her insulin. Currently, she is problem. The second occurs when patients improving but requires a urinary catheter and refuse recommended treatment, especially must keep her legs elevated at rest.

5 She says when they are not willing to discuss the she is now able to take care of herself and refusal, when the reasons for the refusal are wants to return home. Does this Patient have not clear or when the refusal is based on mis- the capacity to make this decision? information or irrational biases. The third occurs when patients consent to particularly CASE 2 risky or invasive treatment too hastily and A 78-year-old man has a recent diagnosis of without careful consideration of the risks and metastatic cancer of unknown primary.

6 He benefits. The last scenario occurs when pa- returned to the office today after having a tients have a known risk factor for impaired JULY 15, 2001 / VOLUME 64, NUMBER 2 AMERICAN FAMILY PHYSICIAN 299. ences chest pain may be able to understand Physicians are called on to make decisions about patients ' the need for antibiotics to fight pneumonia capacity, not competency, which is a legal issue. but not the indications for, or the risks and benefits of, cardiac catheterization and angio- plasty for coronary artery disease.

7 Decision-making, such as a chronic neurologic How to Assess Capacity or psychiatric condition, a significant cultural Once a Patient has been identified as or language barrier, an education level con- requiring a more careful assessment of capac- cern, an acknowledged fear or discomfort ity, the evaluation should proceed in a clear with institutional health care settings or who and organized ,4-6 Physicians may are at an age at either end of the adult spec- use a directed clinical interview or a formal trum (adolescents younger than 18 years or capacity assessment tool .)

8 Adults older than 85 years). patients exemplifying one of these scenar- DIRECTED CLINICAL INTERVIEW. ios require careful assessment but may still be Ancillary tests may be needed, depending on able to make their own decisions. Some the individual circumstances, including his- abrupt mental status changes, for instance, tory from therapists or other caregivers, physi- are only temporary. Some patients refuse cal assessment , laboratory evaluation and pos- treatment for reasons that may be unusual or sibly even neuroimaging studies.

9 These tests idiosyncratic but are not irrational when may all help clarify whether the current level of examined in more detail. Other patients con- functioning and, possibly capacity, is likely to sent to treatment without apparent consider- improve. Table 11,4-6 outlines specific Patient ation of risks and benefits because they have abilities to be assessed along with suggested already decided to follow the recommenda- questions to assess each ability during a tions of their physician. Many patients with directed clinical interview.

10 After these abilities neurologic or psychiatric conditions,2,3 or are assessed, a general mental status examina- those who are younger than 18 or older than tion also must be performed to determine 85 years, are able to make decisions about whether any serious psychopathologic factors some aspects of their medical care. may be unduly influencing Patient thinking. Decision-making capacity, medical or oth- The clinician's final assessment of whether a erwise, is always specific to the task requiring Patient has medical decision-making capacity the ,4 Certain patients may be able depends on whether the clinician believes that to decide some aspects of their care, but not the Patient is free of significant psychopatho- others.