Capacity Nancy Weintraub, MD, FACP Professor of Medicine, UCLA Director, UCLA Geriatric Medicine Fellowship Director, VA Special Advanced Fellowship in Geriatrics at GLA VA

What is Decision Making Capacity? The ability to make rational decisions Can be medical decisions, financial decisions, placement decisions, etc. Decision specific Sliding scale: Decisions with greater potential for harm may require a higher level of capacity

Who Decides? All physicians can judge a patient's capacity to make decisions Psychiatric and neurologic consultation may be helpful Evaluation for patients who speak a language other than English requires an interpreter

How? Ability to communicate Ability to understand the proposed treatment and alternative interventions Ability to appreciate the consequences of accepting or declining the suggested treatment Ability to make a choice and to explain the rationale for their choice

Communicate Translator Hearing Aides or Pocket Talker Pen and Paper Need to pursue all possible means to communicate, e.g. Translator Hearing Aides or Pocket Talker Pen and Paper Braille Yes/no questions in person who is intubated

Understand Tell me the options Tell me the outcomes of each option What’s wrong? How can we treat it? Tell me the options Tell me the outcomes of each option

Appreciate Acknowledge the problem (possess insight) Manipulate the information Be able to explain the underlying medical (or other) problem and why it occurred Explain why certain courses of treatment are recommended

Make a Decision Inability to decide may indicate lack of capacity Frequent changes of decision may indicate lack of capacity Poor memory does NOT necessarily mean lack of capacity

Ability to explain the Rationale Importance of PROCESS of decision making NOT the decision Patients are allowed to make bad choices

Capacity may be limited by internal and external factors. Capacity may be gained or lost. May require re-evaluation Clinical maneuvers may enhance capacity: Depression -> pharmacologic or talk therapy Delirium -> remove medications, treat disease, timing Somnolence -> remove medications, treat disease Psychosis -> pharmacologic therapy Cultural misconnection -> recognize, consider match

Capacity vs. Competence

Competence and incompetence are legal terms, implying actions of a court of law. Capacity is specific to the medical (or other) decision at hand, decision made by a physician

Capacity to Consent Ability to communicate Ability to understand the proposed treatment and alternative interventions Ability to appreciate the consequences of accepting or declining the suggested treatment Ability to explain the rationale for their choice