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

2. 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

3. 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

4. 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

6. 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

7. 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

8. 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

9. 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

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

11. 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

12. Capacity
vs.
Competence

13. 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

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