When and how to assess decision-making capacity in your patients

Clinical question

When might I need to assess decision-making capacity in a patient and how should I approach the discussion?

Bottom line

Questions about decision-making capacity can be a substantial concern for patients, families, and health care providers. Legislation about medical decision making varies by province, so clinicians should be aware of the laws in their jurisdictions. Capacity is best considered as decision-specific, and all physicians can assess capacity for specific medical decisions; they do it quite often without necessarily being aware of the process. Capacity is commonly defined as a person’s ability to understand the information relevant to making a personal decision in a specific domain and to appreciate reasonably foreseeable consequences of the decision. An interview assessing capacity should examine context, choices, and consequences.

Evidence

• Impaired decision-making capacity in patients can result from developmental or disease processes, cognitive impairment, neurocognitive disorders, or brain injury.^1,2

• Decision-making capacity is an important issue for the health care system.^3,4

• As the life expectancy of Canadians and the prevalence of cognitive impairment continue to rise, health care professionals will encounter more situations where capacity is a consideration.^1,2

• This topic is covered in an article in the Canadian Geriatrics Society Journal of CME.⁵

Approach

A decision-making capacity assessment is conducted by health care professionals in some Canadian provinces to determine if sufficient evidence exists to declare a patient incapable of managing their affairs. A finding of incapacity allows the patient’s agent to act on their behalf by representing the patient’s wishes.⁶ In all provinces and territories, when there is concern about a person’s ability to understand and appreciate aspects of a specific medical decision, physicians must assess and document capacity.

When to consider medical decision-making capacity. Legally and ethically, physicians are considering capacity whenever they discuss medical care with a patient. Family or caregivers, involved physicians, or other health care professionals may raise questions about an individual’s ability to understand and appreciate a medical decision. A low score on a cognitive test may raise concern, but should be considered in the context of the individual (including education level and previous functioning).

Capacity should be formally assessed when a patient displays behaviour or makes decisions that put the patient or others at risk; when a diagnosis of dementia or reduced cognitive function leads to concerns about impaired decision making based on knowledge of cognitive deficits or past concerns; or when a patient makes medical choices inconsistent with previously held values.^6,7 When clinicians note patient difficulties understanding treatment discussions, underlying capacity should be considered.

Stages of capacity assessment. There are 3 steps to capacity assessment (Figure 1).⁶ Step 1 is ensuring a suitable reason for assessment. Step 2 includes stabilizing the patient if needed, collecting information, and problem solving. For example, if a patient who lives alone leaves the stove on, stove timers or meal delivery options can be recommended. In step 3, a capacity interview should only be completed as a last resort when problem solving and alternative strategies cannot resolve concerns. No cognitive test will determine if a patient has decision-making capacity, so gathering information and solving problems is critical.

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Figure 1.

Process of capacity assessment

Clinicians should consider whether a finding of reduced capacity is likely to be time-limited, or present for an extended duration (eg, delirium vs dementia), as this may affect the approach employed. In addition, each province and territory has legislation about how to proceed after a patient is found incapable of making a medical decision. For example, it is a common requirement that a health care provider inform the patient of the provider’s finding and communicate avenues to appeal the finding.

Implementation

Interview templates can be used, or the interview can centre on context, choices, and consequences (the “3 Cs”).⁶ After fully informing the patient of their options, clinicians should ask themselves if the patient knows

• the context or problems that are an issue,

• the choices or options available for each of the problems, and

• the consequences of choosing or not choosing an option.

This mirrors the other definitions of capacity, which is commonly defined as the ability of a person to understand information relevant to making a personal decision in a specific domain and to appreciate reasonably foreseeable consequences of the decision. Understanding can be determined by clarifying the patient’s factual knowledge and ability to comprehend the nature of a decision. Appreciation can be classified as the patient’s ability to ascertain the consequences of the decision and justify their choice.⁸ The Aid to Capacity Evaluation tool (https://www.cmpa-acpm.ca/static-assets/pdf/education-and-events/resident-symposium/aid_to_capacity_evaluation-e.pdf) can be useful in assessing capacity for specific medical decisions.