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Chapter 7

Competency: What It Is, What It Isn’t, and Why It Matters

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Why is Competency an Issue?

• Competent adults have the right to refuse treatment.

• But when a person refuses life saving treatments, we become uneasy.

• We find our refuge in the idea of competency. • Therefore, it is important to understand what

it is and how it impacts practice

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Consider Competency

• It is not a medical judgment. • It may not be based on rational thinking. • It is a legal and social decision about the

ability to make decisions. • The criteria used is not precise and may

include our prejudices.

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Seeking a Definition

• There is no standard definition that fits all cases.

• Rules of competency differ by situation. • Definitions are divided into those that

represent end results, and • Those that represent processes.

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Seeking a Definition

• Definitions concerning end results ask: • What is the patient’s condition? • What are the end results of the patient’s

thinking and decision? • Would an incompetent person make decisions

that lead to serious consequences? • However, this definition may not work in all

cases.

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Seeking a Definition

• Definitions also include thought processes. • These definitions examine a patient’s view of

reality and ability to make rational judgments. • You need to determine if the patient is making

sense in his or her decisions. • There is a need to determine the essence of

competency to define it.

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The Essence of Competency

• Competency involves the patient’s ability to make a decision in any given situation.

• First, the patient must understand the situation to make a competent decision.

• Determining patient’s understanding level may be difficult in situations which can lead to end of life.

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The Essence of Competency

• We define rational as being sensible to our way of thinking.

• We use the idea that most people would want the treatment as a criteria.

• Patients who make decisions based on facts and logic appear to be competent.

• If the decision does not logically flow from the facts, we see the patient as being incompetent.

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Religious Refusals

• Religious beliefs need to be considered differently since they may not appear to be rational.

• In this case, the patient is competent if he/she understands the situation and is making a decision based on religious beliefs that are within our common understanding.

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Religious Refusals

• Think about the decision processes of patients A and B.

• Both demonstrate “irrational” thinking but Patient A’s belief fits within our understanding of religious faith.

• Patient B would be seen as incompetent because the decision is not based on an understood faith.

• This criteria is also used in court cases.

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Religious Refusals

• Think about the decision processes of patients C and D.

• Patient C would be considered incompetent because her belief is outside of common religious practice and she does not understand her situation.

• What about Patient D?

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Conclusions Related to Competency

• What would a Medical Miranda Card say about refusing medical treatment?

• If the answers to all four questions shown in the Chapter are “yes”, the patient should be considered competent.

• If the answer to any of them is “no”, the competency is not assured.

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Why it Matters

• Consider what happens when you decide that a patient is not competent.

• You force your choice on a person against his/her will.

• You are making a decision that affects the person’s nature.

• You negate the person’s autonomy in an effort to assure your determination nonmaleficience and beneficence.

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Conclusions

• You must determine competency before you decide to accept a patient’s refusal.

• Competency is a label we give to patients who understand their situation and whose reasons for choices make sense to us.

• It is a serious action to declare a person incompetent and make choices for him/her.

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In Summary…

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