DQ 7-1

1.

“Competency refers to the mental ability and cognitive capabilities required to execute a legally recognized act rationally (Leo, 1999, p.132). Typically, the court determines if a person is incompetent and then they assign a guardian to make decisions on the patient’s behalf. According to Leo (1999), in order for the judicial court to find someone incompetent there has to clear and convincing evidence from licensed health care providers and others that displays the reasons why they believe a patient should be deemed incompetent.

“Capacity refers to an assessment of the individual’s psychological abilities to form rational decisions, specifically the individual’s ability to understand, appreciate, and manipulate information and form rational decisions” (Leo, 1999, p.132). Capacity is typically determined by a physician or psychiatrist. According to Leo (1999), there are four categories that are reviewed to determine whether the patient has the capacity to make decisions. They are ability to evidence a choice, ability to understand relevant information, ability to appreciate the situation and its likely consequences, and the ability to manipulate information rationally. An easy way to determine whether a patient has the ability to evidence a choice is “by asking patients who have been informed about their medical condition and proposed intervention to respond to what they have just heard” (Leo, 1999, p.134). The patient should be able to in their own terms restate back what they just heard. Asking the patient questions about whether they understand the propose treatment and the consequences of the treatments or interventions, will assist physicians and psychologists in determining whether the patient has the capacity to make sound decisions. 

If a patient is deemed to lack capacity, the physician will need to proceed with caution when it comes to providing care. If there is an urgent medical issue that arises, the physician can act under implied consent, however “it is advisable to obtain the opinion of another physician to support the decision to act under implied consent. The second physician’s statement, documented in the medical record, should likewise reflect the need for expediting treatment owing to the danger of postponing it” (Leo, 1999, p.140). If the patient has an advanced directive such as a Do Not Resuscitate (DNR) then the provider can’t perform CPR or intubate the patient to help, if they code. When a patient appears to be lacking capacity, the physicians need to try and locate a family member who can act as a surrogate of the patient to try and make sense of the situation and ask them to help make decisions. Family members typically know what the patient’s wishes are and can assist the physicians with proper care moving forward.

Reference: Leo, R.J. (1999). Competency and the capacity to make treatment decisions: a primer for primary care decisions. The Primary Care Companion, 1(5), 131-141.

2.

Informed consent is when a physician must effectively communicate to a patient the situation including describing the illness, treatment options, associated risks and benefits, potential complications, and any alternatives-including the option of no treatment. They must fully inform the patient and allow them to make their own decisions without coercion. In order for a physician to effectively do this the patient must have the capacity to make a decision. Hospitals treat patients that may not have the capacity or competency to make autonomous decisions for example, patients that are depressed, under psychosis, dementia, stroke, personality disorders, developmental delays, comatose, or impairment. When hospitals employees are faced with situations where a patient’s capacity is being questioned and they have to make a decision if the patient is mentally competent enough to make their own decisions or not. Four components that a hospital can use to determine to determine a patient’s capacity are; communicate their choice, understanding, appreciation, and rationalization/reasoning (Dastidar & Odden, 2011).

Communication- the patient should be able to express a treatment choice.

Understanding- The patient should be able to recall conversations about treatments and the probabilities of outcomes. Problems with remembering, their attention span, and intellect could affect their ability to understand.

Appreciation- The patient should show that they can distinguish the illness, treatment options, and outcomes and how they could directly affect them. (A lack of appreciation would be denial based on intelligence or emotion)

Rationalization/Reasoning- The patient should be able to weigh all the options, with consideration of risks and benefits, and come to a conclusion based on what is in their best interest- based on personal goals and values. (This can be affected when psychosis, depression, anxiety, phobias, delirium, and dementia exist)

Dastidar, J., & Odden, A. (2011). How Do I Determine if My Patient has Decision-Making Capacity?. Retrieved from https://www.the-hospitalist.org/hospitalist/article/124731/how-d

3

The courts are the predictors that determine if patients are mentally competent to make their own decisions. Competence is a legal term. Individuals are presumed competent and able to full exercise their rights as citizen (Gibson & Ferrini, 2010).

Capacity describes a person’s ability to a make a decision. In a medical context, capacity refers to the ability to utilize information about an illness and proposed treatment options to make a choice that is compatible with one’s own values and preferences (Tao & Janofsky, 2017).

Competency is the degree of mental soundness necessary to make decisions about a specific issue or to carry out a specific act. A determination of competency is a judicial finding made by the court. A physician can opine about a patient’s capacity but cannot determine competency (Tao & Janofsky, 2017).

Adults are presumed to have capacity unless determined otherwise by the court. A person who lacks capacity to make an informed decision or give consent might need to be referred for a competency hearing or have a guardian appointed. Psychiatrists often are called on to provide an opinion to the court regarding a person’s capacity. Psychiatrists are particularly skilled at accessing a person’s mental status and gauging its potential for interfering with specific areas of functioning, but, in fact, any physician can make a determination of capacity (Sorrentino, 2014).

References:

Gibson, R. M., & Ferrini, R. (2010, October). You Let Them Do What??!! Decision-Making Capacity and the Exercise of Patient Autonomy in LTC. Retrieved from Annals Llong-Term Care: https://www.managedhealthcareconnect.com/content/you-let-them-do-what-decision-making-capacity-and-exercise-patient-autonomy-ltc

Sorrentino, R. (2014, January 13). Performing Capacity Evaluations: What’s Expected From Your Consult. Retrieved from MDedge Psychiatry: https://www.mdedge.com/psychiatry/article/79219/practice-management/performing-capacity-evaluations-whats-expected-your

Tao, A., & Janofsky, J. S. (2017, August 2). Capacity, Competency, and Guardianship. Retrieved from John Hopkins Psychiatry Guide: https://www.hopkinsguides.com/hopkins/view/Johns_Hopkins_Psychiatry_Guide/787159/all/Capacity__Competency__and_Guardianship