City Colleges of Chicago Evaluating Decision Making Capacity Case Study Choose one of the case study and write a maximum of 2 pages in strict AMA style Eva

City Colleges of Chicago Evaluating Decision Making Capacity Case Study Choose one of the case study and write a maximum of 2 pages in strict AMA style Evaluating Decision-Making Capacity: A Basic Primer on Concepts
As many trainees may remember from ethics training or self-directed study, decision-making capacity is
generally not considered to be equivalent to competency. Competency is a more global descriptor that is
determined in a court of law; although there can be variability in the definition of “competency,” it typically
describes a person’s ability to care for himself/herself and make decisions about a broad range of topics. In
contrast, decision-making capacity describes the ability to make a specific decision at a specific time.
Unlike a determination of competency, decision-making capacity can be fluid and may change over the course
of an illness or treatment. As an example, a patient who is lethargic upon initial presentation may not have
decision-making capacity when admitted, but, if successfully treated, may regain capacity to make decisions
over the course of his or her hospitalization.
It is also possible for an individual to have capacity to make one decision, but not another, at the same time. As
an example of this, a patient with mild cognitive impairment may be able to fully grasp the relative risks and
benefits of a recommendation to begin a medication s/he already has familiarity with and has taken
previously, but may not be able to understand the potential risks and benefits of a complex procedure. In this
example, a patient may be more likely to have decision-making capacity in the first scenario, but not the latter.
There are four generally accepted criteria that a patient must meet for decision-making capacity to be deemed
intact:
1. Ability to understand the pertinent medical information
2. Ability to appreciate one’s situation and potential outcomes or consequences
3. Ability to arrive at a decision through reasoning
4. Ability to communicate a choice
Given that decision-making capacity can fluctuate over time, these four elements need to be assessed on an
ongoing basis.
Let’s look at these requirements a little more closely to understand what they mean. The first requirement, the
ability to understand the pertinent medical information, means that the patient is able to comprehend
essential medical information delivered by his or her team, including the nature of his/her condition, the
recommended treatments and alternatives, and relative risks and benefits of treatments (or non-treatment).
For example, this might involve understanding what “meningitis” means, what an antibiotic is, or what the
general approach to a recommended surgical procedure might look like. This does not need to be at the level
of understanding or detail that would be expected of a medical professional but should be enough to
appropriately evaluate risks and benefits and inform the decision-making process. Some examples of questions
that can be asked to help determine if the patient meets this criterion include:
• Could you please explain to me what you’ve been told by your treatment team about your
medical diagnosis?
• What is your understanding of what “sepsis” (or whatever patient’s diagnosis is) means?
• What is your understanding of the ways this may be treated?
• What would be some of the possible benefits of treatment? What would be the potential risks?
The second criterion, an ability to appreciate one’s situation and potential outcomes, overlaps to some degree
with the first criterion described (understanding the relevant medical information). This second criterion
refers to a patient’s ability not just to understand medical information, but also to understand and appreciate
how this information applies to his or her own unique situation. This includes an appreciation for the
seriousness of one’s condition and the ability to understand and describe potential consequences of medical
choices for one’s particular situation. An example of a situation in which a patient might meet criteria #1
(medical understanding) but not criteria #2 is a patient who expresses understanding and awareness of the
risks of refusing treatment in an abstract sense, but also expresses certainty that this outcome would never
happen to him or her in particular, without medical evidence to substantiate this belief. Examples of questions
to assess this criterion include:
• What do you think about your diagnosis?
• Do you think anything is wrong with you?
• Do you think you need treatment?
• What do you think will happen if you don’t have treatment?
• What do you think is likely to happen if you do have treatment?
The third criterion, an ability to arrive at a decision by a rational thought process, can be more difficult for
doctors to understand and assess. Sometimes, if a patient disagrees with a physician, it is hard for the
physician not to think that the patient is irrational. However, as long as there is internal logic and it is
consistent with the patient’s usual values and beliefs, a patient’s thought process can be rational even if it is in
disagreement with the physician’s recommendation. As an example, a patient may refuse a procedure that
carries a 1% risk of serious disability. This may seem illogical to a physician who knows that the absolute risk of
bad outcome is low; however, if the type of disability (e.g. vision loss) is completely unacceptable to the
patient, he or she may choose to refuse the procedure based on a logical reflection on his/her values. If not
obvious, this can often be assessed by asking why or how a patient arrived at a particular decision. Family
members or close supports may also be able to help provide helpful collateral regarding whether a patient’s
decision-making process is consistent with his or her usual thought process and values. Examples of questions
to assess this criterion include:
• Could you please tell me more about how you arrived at your decision?
• Could you talk me through how you decided to decline treatment (consent to a risky procedure,
etc)?
• Why is your decision a better option for you than the alternative?
The final criterion, the ability to communicate a decision, is more straightforward. It simply requires that the
patient be able to communicate a clear preference or decision to providers. The decision also should be
consistent, within reason. For example, if a patient expresses frequent inconsistencies or changes in their
decision, as might occur in a delirious patient or one who did not truly understand the situation, the patient
would likely not meet this criterion. However, , a patient who initially expresses one decision, but then
expresses another after additional research on the topic, careful reflection, time to discuss with additional
trusted providers, etc ,should have the new decision respected, provided all of the other necessary criteria are
met.
RECOMMENDED RESOURCES
Appelbaum PS. Assessment of Patients’ Competence to Consent to Treatment. N Engl J Med 2007; 357:18341840.
Most general psychiatry texts, and consult-liaison psychiatry texts, also can provide additional background and
explanation for those interested in further reading.
Evaluating Decision-Making Capacity: Cases
Case 1
Mr S is a 37-year-old male with mild intellectual disability admitted for treatment with IV antibiotics for
cellulitis. He lives independently and works part-time stocking shelves at a local retail store. Prior to
completing his IV antibiotic course, he demands to leave the hospital. When asked why he wants to
leave, he expresses frustration at the length of his hospital stay, states that he has mail and bills piling
up at home, that his cat is alone, and that he wants to get out of the hospital in time to buy a birthday
present for his nephew.
When reminded that his medical care team recommended that he stay for an additional two days to
complete his antibiotic course, he states “But I feel fine. My energy is great, I don’t have a fever, and it
doesn’t hurt that much at all. I’m fine. Besides, I really need to get home – there’s a lot to do. I just need
to get this thing out of my arm [gestures to the IV], then I’ll call a cab and head home.”
Based on the information you have so far, does it appear that Mr. S has decision-making capacity to
leave the hospital AMA?
What additional information would you like? What would be your next step?
Case 2
Mrs. R is a 68-year-old retired nurse who formerly worked in the ICU. She has recently been admitted to
the hospital for altered mental status and a fever. The ED team is in the process of working up her
illness, and a nurse has just gone to her room to obtain a straight cath urine specimen, as the patient
was unable to provide one voluntarily. Suddenly, a clatter and shouts emanate from her room – she has
turned over her tray and has thrown her blankets to the floor. She yells “Get that catheter away from
me!” and orders the nurse from her room.
When the medical student assigned to her care re-enters her room, she is found crouching in the corner,
wearing only a hospital gown. She is plucking tissues out of a tissue box one by one and arranging them
in a pile on the floor. When the medical student announces her presence by saying “Excuse me, Mrs. R. .
. .?,” the patient looks up and replies “Oh, hi, honey. I’m so glad to see you. That witch was saying I
might have a UTI. I don’t have a UTI! I’m a nurse, and I know I don’t have a UTI. This isn’t even a real
hospital! Be quiet, quick, come over here. If we just wait long enough, they’ll stop paying attention and
we can sneak out.”
Based on the information that you have, does it appear that Mrs. R has decision-making capacity to
refuse the catheter?
What would your next steps or questions be?
Case 3
Mr. B is a 50-year-old married father of two, with a history of colon cancer, admitted to the hospital for
evaluation and management of weakness, fatigue, and pre-syncopal episodes. Although his colon cancer
had been treated to apparent remission with surgical resection and chemotherapy several years prior,
medical work-up on this admission reveals significant anemia, presence of a mass at the site of his
previous resection, and likely metastases to the liver. Following his work-up and a blood transfusion, he
is informed by his care team of the recurrence of his colon cancer. The treatment team recommends
repeat surgery to resect the new colonic mass, as well as adjunctive chemotherapy. While not expected
to drive his cancer into remission, it is anticipated that treatment as recommended would likely prolong
life for 1-2 years. Without treatment, prognosis is much more guarded, although the team does note
that it will be difficult to determine an exact prognosis without additional information, including further
assessment of the recurrent mass through surgery and evaluation by pathology.
The following day on rounds, Mr. B tells his team that he does not want to pursue the recommendations
for surgery and chemotherapy. He states “I’ve thought this over. The recovery from surgery, and then
the chemotherapy. . . . It was awful last time. I couldn’t do anything. I couldn’t be the person I wanted
to be with my wife and kids because I felt so awful. I can’t do that again. I just want to let this pursue its
natural course and spend as much time with my family as I can, while I still can.”
Does Mr. B appear to have the decision-making capacity necessary to make this decision?
What would you do next?

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