1. Capacity Nancy Weintraub, MD Health Services Professor, UCLA VA GRECC
Director, UCLA Geriatric Medicine Fellowship

2. DISCLOSURES None of the faculty, planners, speakers, providers nor CME committee has any relevant financial relationships with commercial interest There is no commercial support for this CME activity

3. Case 84 year old woman w/ DM and HTN in ED
CC: abdominal pain worsening over past few days, now severe
PMH: OA, Hearing Loss, Macular Degeneration
PSH: TAH due to fibroids many years ago
Meds: glipizide, metformin, lisinopril, HCTZ, acetaminophen

4. SH: Lives with husband for whom she is the care-giver after his CVA; retired teacher; 2 daughters in the area; no tobacco or alcohol
ADLs independent
IADLs:
Does not drive (never did)
Manages all medications
Manages finances
Does the cooking
Daughters help with shopping and cleaning

5. Pertinent PE Vitals: BP 110/60, HR 120, T 100.4
Pt moaning in pain, calling for her daughter
Lungs clear
Cor RRR S4S1S2 w/ 2/6 sys m
Abd: BS absent, + guarding
Neuro: moving all 4 extremities

6. Labs H/H 11/33, WBC 17.5 w/ L shift, plts 280 K
Na 145, K 3.2, Cl 105, CO2 20, AG 20
Glu 300, BUN 45, Cr 1.3, LFTs nl
EKG: sinus tach
CT abd: free air and stranding around L descending colon

7. CONSENT
(oh no)

8. Who consents?

9. Capacity
vs.
Competence

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

11. 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

12. The Saga Continues…. You explain.
She says: “I don’t understand you. I don’t know . Talk to my daughter.”

13. What now????

14. 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

15. Is the patient delirious? How do we find out?

16. CAMS 1. Acute change in mental status and fluctuating course
2. Inattention
3. Disorganized thinking
4. Altered level of consciousness
Requires features 1 and 2 and either 3 or 4

17. 1. Acute change in mental status and fluctuating course
Do we have that? How do we find out?

18. 2. Inattention
Do we have that? How do we find out?

19. Short mental status testing
Conversation

20. 3. Disorganized thinking
4. Altered level of consciousness
Observation and conversation

21. Back to the patient….
You try to assess her mental status and discover that she cannot hear you.
Now what?

22. 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