II. Definitions
-
Informed Consent
- Patient willingly participates in medical therapy
- Requires understanding what is involved with the proposed therapy
-
Mental Competency
- Sufficient understanding and memory to comprehend their own situation
- Understanding of the consequence of their proposed actions
- Competence is determined by a judge
- May indicate whether a person may stand trial
- Can they distinguish truth from fiction
- Can they assist their attorney in their own defense
- Medical Decision-Making Capacity
- Ability to communicate, understand the information they are given
- Ability to make logical decisions based on given information
- Ability to understand their current medical status or condition
- Ability to understand options for medical care
III. Indications: Capacity Assessment
- Abrupt change in mental status
- Refused recommended treatment without adequate reason
- Accept risky treatment without adequate processing
- Known risk of impaired decision making
IV. Evaluation: Decision making capacity (See ACE below and Curves Mnemonic)
- Does the patient understand condition and treatment?
- What is your understanding of your condition?
- What are the options for your situation?
- What are the benefits of treatment and the likelihood the treatment will offer you benefit?
- What are the risks of treatment and the likelihood you will have a bad outcome?
- What is likely to happen if you do nothing?
- Can patient apply information to their own condition?
- Tell me what you think about your current medical condition?
- What are your medical providers offering for treatment?
- What treatment do you think is best for you?
- Reasoning consistent with the facts and their values?
- What are you thinking about while making your decision?
- How do you balance the advantages and disadvantages of treatment?
- Can the patient communicate their choices clearly?
- Have you decided what medical treatment is best for you now?
V. Evaluation: Cognition
VI. Evaluation: Capacity
-
CURVES Mnemonic for Capacity Assessment
- Mnemonic that can be used quickly at the point-of-care (e.g. Emergency Department) to assess capacity
- Aid to Capacity Evaluation (ACE) by Dr. Etchells
- Structured interview divided into 7 domains
- Patient understands current medical problem, proposed treatment, and alternatives (Domains 1-4)
- Patient appreciates consequences of their decisions including withholding treatment (Domains 5-6)
- Patient does not have mental illness (Major Depression, Psychosis) impacting their decisions (Domain 7)
- ACE Web Resource (freely available for online download)
- Structured interview divided into 7 domains
- Hopkins Competency Assessment Test (HCAT)
- Competency evaluation based on the reading of a 4 paragraph essay followed by questions
- Can be performed in 10 minutes by a non-clinician
- MacArthur Competence Assessment Tool for Treatment (MACCAT-T)
- Structured interview by clinician with rated responses
VII. References
- Herbert, Henry, Arambasick and Orman in Herbert (2014) EM:Rap 14(11): 4-5
- Bradford-Saffles and Arambasick (2013) Crit Dec Emerg Med 27(6): 11-5
- Barstow (2018) Am Fam Physician 98(1): 40-6 [PubMed]
- Etchells (1999) J Gen Intern Med 14:27-34 [PubMed]
- Freedman (1991) Ann Intern Med 115:203-8 [PubMed]
- Tunzi (2001) Am Fam Physician 64(2):299-306 [PubMed]