Fast Fact and Concept #55: Decision Making Capacity

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Title: Fast Fact and Concept #55: Decision Making Capacity

Author(s): Robert Arnold

Informed consent is based on the principle that patients should be allowed to make decisions for themselves. Decision making capacity thus serves as a gatekeeper concept - patients who have it can make decisions for themselves; conversely, a surrogate is needed for patients who lack decision-making capacity. Note: Competency is a legal term referring to a decision made by judge, although a physician's opinion carries a large amount of weight in a competency hearing. In contrast, Decision-Making Capacity (a.k.a. decisional) refers to a physicians' determination, based on clinical examination, that a patient is able to make medical decisions for themselves. Most state Power of Attorney for Health Care documents require a physician to document that a patient has lost Decision-Making Capacity for the surrogate to become the legal agent for medical decisions.

To be deemed Decisional, a physician must be satisfied that a patient is able to: 1) receive information (e.g. must be awake, but not necessarily oriented x 4), 2) evaluate, deliberate, and mentally manipulate information and 3) communicate a treatment preference (e.g. the comatose patient by definition is not decisional). The following points expand on the concept of decisionality. Decision-Making Capacity is:

Understanding. Does the patient truly understand the information about the risks, benefits, and alternatives of what is being proposed? The patient does not have to agree with your interpretation, but should be able to repeat what you have said. Ask, "Can you repeat to me the options for treating X I have just discussed with you?" Can you explain to me why you feel that way?

Task specific. Deciding if the patient is decisional means weighing the degree to which the patient has decision-making capacity against the objective risks and benefits to the patient. Some decisions are more complex than others, requiring a higher level of decision-making capacity. Thus a moderately demented patient may be able to make some decisions (e.g. antibiotics for pneumonia) but not others (e.g. chemotherapy for metastatic lung cancer). This sliding scale view of decisionality holds that it is proper to require a higher level of certainty when the decision poses great harm.

Logical. Is the logic the patient uses to arrive at the decision "not-irrational"? One wants, as much as possible to make sure the patient's values are speaking, rather than an underlying mental or physical illness. Note: Severe depression or hopelessness will make it difficult to interpret decisionality; consult psychiatry for assistance with this or other complex cases.

Time specific. When encephalopathic, a patient may not be decisional, while after treatment decisionality may be regained.

Consistent. Is the patient able to make a decision with some consistency? This means not changing one's mind every time one is asked. Is the decision consistent with the patient's values; if there is a change in the patient values, can the patient explain the change.

Also See:
Fast Fact #56: What to do when a patient refuses treatment

Drane, J. F. (1985). "The Many Faces of Competency." Hasting Center Report: 17-19.
Practical ethics for students, interns and residents. A Short Reference Manual. Junkerman C and Schiedermayer D. Second Edition. University Publishing Group, 1998.

Copyright and Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing. Fast Facts and Concepts #55 . Arnold R. Decision Making Capacity. November, 2001. End-of-Life Physician Education Resource Center www.eperc.mcw.edu.

Fast Facts and Concepts was originally developed as an end-of-life teaching tool by Eric Warm, MD, U. Cincinnati, Department of Medicine. See: Warm, E. Improving EOL care--internal medicine curriculum project. J Pall Med 1999; 2: 339-340.

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Creation Date: 11/2001

Format: Handouts

Purpose: Instructional Aid, Self-Study Guide, Teaching

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Keyword(s): Decision making capacity/surrogates

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