Time Stamps

• 2:07 Introduction to decision making
• 4:12 Choice
• 8:24 Understanding
• 11:33 Appreciation
• 14:10 Reasoning
• 22:12 Common myths and misconceptions
• 25:11 When and how to call a psychiatry consult for capacity assessment
• 28:07 Conclusion

Show Notes

• Introduction
  • What is decision-making capacity? Why does it matter? How is it assessed? 
  • We are responsible as clinicians to give patients the best chance to demonstrate capacity
• Four components of the capacity assessment
  1. Choice
     • Can the patient communicate? How can we as physicians ensure clear communication with our patients?
     • Can the patient maintain a choice long enough for it to be implemented?
  2. Understanding
     • Can the patient process and retain new information?
     • Can the patient ‘teach-back’ that information?
     • What role does plain language serve in ensuring patient understanding?
  3. Appreciation
     • Does the patient recognize her medication condition and the decision she is making?
     • Does the patient appreciate the potential consequences this decision has on her own life?
     • Can the patient internalize the information and understand the direct effect it has on her life?
     • In a 2018 paper, Barstow and colleagues suggested a few practical questions that start to help us tease it out.
       • Tell me what you really believe about your medical condition.
       • Why do you think your doctor has recommended this specific treatment for you?
       • What do you think will actually happen to you if you accept this treatment? And what about if you don’t accept it?
  4. Reasoning
     • Can the patient manipulate information rationally?
     • Do her decisions reflect her beliefs and values?
     • How did they come to the conclusion?
     • What role do we as physicians play when our beliefs and decisions vary from our patients?
     • Ex. of questions that you can ask to assess reasoning:
       • How did you come to that conclusion?
       • How are you balancing the pros and cons of the different options? 
• Common myths and misconceptions
  • Capacity is not universal or static; it is time- and decision-dependent
  • Patients with dementia or psychiatric diagnoses do not uniformly lack capacity
  • Capacity (clinical evaluation) vs competency (legal decision)
• When and how to call a psychiatry consult for capacity assessment
  • Especially difficult cases
  • Required by law in some states when a patient has a psychiatric diagnosis
  • Request help to assess capacity for a specific decision
• Conclusion

Transcript

INTRODUCTION

Margot: He wasn’t my first patient to try to leave against medical advice, but he was the first patient who I thought would actually die if he walked out the door. He was an older man with advanced COPD, and he was hospitalized with such a severe pneumonia that he nearly ended up intubated. At the time that I met him, he was on max settings of HFNC, requesting politely but firmly to go home. I told him how concerned I was, pointed out that his oxygen levels dropped to the 70’s every time he took off his oxygen, but nothing I said was getting through. He just kept telling me, “I’ll be fine, doc. I’ll be fine.”

This was an unsettling case for me, and this patient was part of the reason we ended up doing an episode on AMA discharges. But after months of thinking about this case, I realized the real issue wasn’t that he wanted to leave against medical advice. The issue was that that despite an hour of talking, an hour of discussing risks and benefits in every way I could imagine, we still couldn’t seem to understand each other. The issue was that he didn’t have capacity to leave, and that’s what we want to talk about today.

I’m Margot, an internal medicine resident at NYU.

Tamar: I’m Tamar. I also trained in internal medicine at NYU and am now a postdoc in the Division of Medical Ethics. 

Jafar: And I’m Jafar, a hematology/oncology fellow at UCLA. 

Margot: The capacity assessment is the process by which we decide whether a patient is able to make their own medical decisions. To really do justice to this topic, we have a two-part episode for you. In this first episode, we’ll go through the fundamentals of the capacity assessment with Dr. Andrea Kondracke, who we were grateful to have on our podcast.

Dr. Kondracke: Because I’m like, I’m trying to infiltrate your podcast with all the random psych things.

Margot: Dr. Kondracke is double-boarded in internal medicine and psychiatry, and works at Bellevue hospital as the director of the Psychiatry consultation liaison division as well as the psychiatry medical service. Our next episode will discuss some of the ethical dilemmas around capacity.

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Tamar: Let’s start with the basics: What is decisional capacity in medical care and why does it matter? In the most definitional sense, capacity is a person’s ability to make his or her own health care decisions – in practice, this usually distils down to accepting or refusing care options. Now we don’t want to get too theoretical about this, but it is worth quickly asking: why does it even matter? Why do we care if someone has or doesn’t have capacity? We care because of the importance of autonomy, your right to self-determination, to make your own uncoerced and informed choices about your own life. 

And in medical care, the capacity, or ability, to make decisions requires four elements: choice, understanding, appreciation, and reasoning. We’re going to spend the bulk of today’s episode defining and explaining each of these four components. 

Jafar: But even prior to making our assessment, we have to keep in mind one central fact about decision-making capacity: it is time- and decision-specific.  For example, someone can have capacity to nominate a healthcare proxy, but not have capacity to weigh the risks and benefits of a potential surgery.  Likewise, a patient in septic shock might be encephalopathic at that moment, but much more able to talk with you once their blood pressure has stabilized.

Whenever possible, our job as clinicians in assessing capacity is to set up the situation so that our patient has the best chance to make their own decisions. A lot of times, this just means attending to the basics:  if a patient is known to sundown, make sure important conversations are happening in the morning. Try and eliminate distractions, make sure the patient isn’t hungry or in pain, and use plain language.

Of course, look for any reversible causes which may be contributing to delirium: treat the infection, if they’re intoxicated wait for them to sober up, watch for any potential medication side effects, correct metabolic derangements, and make sure any underlying psychiatric disorder is being properly treated.  Capacity can be elusive, but as a basic tenet, if you can wait to look for it, look long and hard before giving up.

COMMUNICATING A CHOICE

Margot: So let’s dive in and start with communicating a choice. While a patient’s choice generally comes at the end of a discussion about risks and benefits, we’re going to talk about this first because without the ability to communicate, the whole capacity assessment falls apart.

To assess this aspect of capacity, you can ask patients questions like: “Based on everything you’ve heard, what would you like to do?” Seems simple enough, right? 

The most obvious problem we run into with this aspect of capacity is communication barriers. And like Jafar mentioned, it’s on us to remove as many of these barriers as possible. I went to medical school in the south, and I once had a patient in the mountains of Appalachia who came in with a stroke. He had a thick Southern accent, and his face was half-paralyzed, and initially none of us knew where his dentures had gone. Ultimately, he ended up being able to communicate pretty well, but first we had to find his dentures and we had to lay his head flat enough to perfuse his brain. Dr Kondracke has another example:

Dr. Kondracke: In other circumstances you can imagine that the patient is unable to demonstrate choice because they’re unable to communicate at all.  So oftentimes you’ll have that with a person who’s trach’ed unable to talk or write or communicate and you’ll try the best you can. 

Margot: There are a ton of potential barriers – noisy rooms, missing hearing aids, or that over-the-phone Bengali interpreter that’s so tough to find at 3 in the morning. About a year ago, I had a patient who only spoke Cantonese and was nearly deaf, so she couldn’t hear the translator phone. We were in the emergency room, which is the loudest place in the hospital. We were able to work around this by calling an in-person interpreter, finding a private room, and basically shouting, but had she been completely deaf, I’m not sure what we could have done. 

But say you’ve sorted out any communication barriers. What if a patient’s not making a choice?

Dr. Kondracke: We often see patients who won’t demonstrate a choice and that can be as simple as saying, “I will decide tomorrow” or you know, “let me think about it” or “I want to talk to my family.” And so in those cases, that’s actually not demonstrating a choice. And that for an emergent procedure or urgent procedure can actually, that kind of delay can can really quite affect the outcome. So I would say that the majority of the time I see this with hip fractures. So, you know, people with delirium, with a hip fracture will often say, I don’t know, ask me tomorrow.  And so it, uh, you know, in that, in that case, we really say, well, that’s not demonstrating capacity because that’s not demonstrating a choice

Margot: Other times, I’ve had patients who do demonstrate a choice, but they keep changing their mind. Sometimes, it’s ok if a patient is dragging their feet:

Dr. Kondracke: You really want a yes or no answer, you know to many of these things. I mean, you know, the blood draw one, it’s like, well yes, I’ll do it tomorrow and that might be okay. You know, tomorrow might be okay to allow some flexibility with this to try to get the patient to make a choice. you know, oftentimes that seems reasonable, you know, to say like, okay, we could delay this for a day cause you really want the patient to, we really want to have the patient be able to make that, you know, to demonstrate capacity.

Margot: It’s perfectly reasonable for patients to want to think through their options, but ultimately, to demonstrate this aspect of capacity the patient needs to communicate a choice, and stick with that choice for long enough for it to be implemented. So we asked Dr Kondracke – at what point do you draw the line?

Dr. Kondracke: At some point you, you sort of put your foot down and say, now with antibiotics, you know, patients that are septic and they’re refusing antibiotics and you’re just, you know, uh, the, the issue is immediate. It has to happen right now. So we need to assess their capacity at this moment and move forward because it’s dangerous not to.

Margot: Essentially, the dividing line is set by the urgency of the decision. Like Jafar said earlier, you want to look long and hard for capacity before saying that it’s not there. But sometimes, you don’t have all day to search.

Finally, what if the patient refuses to talk to you? We see this sometimes in patients who are developing dementia and are worried about giving themselves away, or other times in patients who just don’t like us. The bottom line is, if the patient isn’t talking to you, they’re not proving that they have capacity.

UNDERSTANDING

Jafar: The second part of capacity is understanding relevant information.  Patients with capacity must be able to recall details of conversations about treatment–to process and retain new information.  It’s not enough to just hear a patient say “I need this surgery to save my life.” Instead, you need to hear that the facts have sunk in:    

Dr. Kondracke: So that’s a very important part of that because somebody might be able to weigh the risks and the benefits say, you know, this is, there’s a 50% chance that I would survive the surgery. There’s a 10% chance that I would survive the surgery but lose my leg and there’s a 30% chance I’ll survive the surgery and you’ll also save my leg. Right? So, so that demonstrates a lot of, you know, a lot of understanding.

Jafar: So what we’re talking about here is just a core cognitive skill, and sometimes the easiest deficiency to identify. For instance, patients with advanced dementia who cannot command enough short term memory to internalize new information, or those who are too delirious to maintain their attention during conversation, both clearly lack capacity.  

Other times, it can be more subtle, and trouble in this area may only be revealed when you press the patient to verbalize what they heard.  This kind of “teach-back” request can be a bit awkward in practice, and patients may be too embarrassed to admit what they don’t understand.  One artful way I’ve seen this done is by saying to the patient: “Hey, just so I know that I’ve explained everything right, can you tell me what you understand about your situation and the options in front of us?”   

And if you start to pick up on difficulties here, ask yourself: Is it that this patient just can’t process information, or, is it the way I’ve delivered it?

Dr. Kondracke: That requires you to use the patient’s language, right? So you may be, instead of saying the word endoscopy, saying literally we’re going to put a tube that has a camera on it into your nose, you know, and not even talking about it. And it’s going to look at your stomach. You know, if you say esophagus, they’re like, what does that, you know, I don’t want to, stop this, forget it. So it may be really the requirement maybe for us to talk in a way that the patient can understand. And I think that is missed often, right? With many of our patients who have, you know, no medical background or no medical knowledge, may have not finished high school, may have not finished elementary school, may not speak the language. You know, so, so explaining these things in the patient’s language, you know, whether that’d be simplistically or pictures, you know, I ended up drawing a lot of pictures, trying to get people to understand the process is, is part of this. And if you, if we are not doing our job, then how can we expect the patient to have capacity?

Jafar: When going through this process of trying to explain the relevant information to the patient, one obvious but important point is that you yourself must be able to fully provide it. In some cases you can’t, and so that may mean you need to bring the consultant or proceduralist there to explain it themselves.  What we offer patients can be complicated, even for us on the medical team to understand, and so having that expert there who can break it down and clarify questions is essential to relaying information effectively.  

APPRECIATION

Tamar: The third component of capacity is appreciation. A patient needs to recognize her medical condition or illness and appreciate the potential consequences of her decision. Appreciation and understanding are closely linked and the difference between them can sometimes be a bit vague. But understanding is a patient’s ability to comprehend the general information told to her, while appreciation is her ability to see the implication on her own life — how that information relates specifically to her situation.

Dr. Kondracke: If the patient is able to recite all of the risks and benefits, oftentimes, less practiced physicians would this would end there and say that patient has capacity. We may come in and say, the patient seems to understand the risk and benefits, but they don’t understand how it relates to them. And they’re completely, you know, able to, you know, that’s almost like academic. They can separate, you know, they can intellectualize this, but they can’t internalize that. Right? So that’s that, that’s sort of the difference. And that patient would not have capacity if they don’t understand that, uh, that this may affect them.

Tamar: So how can we try to elicit whether our patients appreciate all the information we give them? In a 2018 paper, Barstow and colleagues suggested a few practical questions that start to help us tease it out. For example:

• Tell me what you really believe about your medical condition.
• Why do you think your doctor has recommended this specific treatment for you?
• What do you think will actually happen to you if you accept this treatment? And what about if you don’t accept it?

And we do recognize that determining a real patient’s real appreciation of a real treatment choice is easier said than done. Dr. Kondracke gave us a great example of putting these strategies into practice:

Dr. Kondracke: If a patient is refusing a life threatening or a life-saving procedure, I will often push that. Honestly, nobody else does this, but push it to, you know, “If you’re not going to do this, then we need to start signing papers for DNR because you are going to, you’re going to watch these young physicians have to let you die. And so let’s do that in a way that can, you know, can be realistic. So, and oftentimes that allows the patient to see the seriousness of this procedure. You know, that, Oh well wait a second, you guys really believe that I’m going to die if I don’t have my leg amputated. And I will, I will oftentimes try to push that conversation to the end result. Like, this is going to lead to fatality. You know, or this is going to lead to your kidneys failing, you know, so try to push this, you know, in a, in a very concrete way that a patient may be under-, able to understand.

REASONING

Margot: The fourth aspect of capacity is reasoning. Can the patient manipulate information rationally? Do they reach conclusions that make sense based on their preferences, their beliefs, and the information their clinicians have provided? As Dr Kondracke explains:

Dr. Kondracke: So the reasoning through is, you know, what would a what would a reasonable person, how would they go about the thought process and, and then be able to explain it to the doctor and have you understand the reasoning behind this.

Margot: To assess reasoning, the patient needs to explain why they’re making the decision that they’re making, and you as the clinician need to be able to understand their thought process. Here are some questions that you can ask to assess reasoning: How did you come to that conclusion? How are you balancing the pros and cons of the different options? 

We’ve got three examples from Dr Kondracke to help illustrate the concept. The first is an example where a patient wasn’t able to demonstrate reasoning:

Dr. Kondracke: We had a we had a man come into the emergency room with what looked like, uh, a compartment syndrome. The surgeons actually called a psych consult and the emergency room because the patient was refusing, any kind of intervention at our hospital. So, one of the reasons he was refusing was because he wanted to go to another hospital where he knew a doctorate and he felt much more comfortable there. So that seems kind of reasonable, you know, and, and the other hospital, not that far away, we could probably even get a cab, you know, for him to go up there. So I was questioning this and, and  you know, uh, and wanted to make sure that we were doing the right thing for this patient, considering he would potentially lose a limb. Uh, you know, if he’s, if this is all kosher then, then we could get the patient there very quickly and you know, potentially be in the OR. However, you know, we want to set this up first. So I called up to the other hospital and I said the doctor’s name and they were like, who? They were like, we don’t have anybody who works here, small hospital, you know, that under that name. And I said, well, will you check to see, you know, in the record who, who this patient saw, who was the patient’s doctor? And they said, Oh, well this patient has only been here for like foot, fungal infection. We gave them, you know, antifungals and they walked out of the ER. So, so then the whole story falls apart. The patient really had no relationship with that doctor because he had only been there once, you know, for a very short time.

Margot: This aspect of the capacity assessment requires a lot of imagination. You need to be able to wrap your head around another person’s value system, and see the decision through their eyes – even if the two of you see the world very differently. For example, I place tremendous weight on health, but many of my patients don’t have their health as their top priority. As a result, it can be really hard for me to understand why a patient would come to a conclusion that could have devastating consequences for them – but at the end of the day, it’s their life to live, and not mine. Dr Kondracke shares another example, where a patient was able to demonstrate reasoning despite making a decision that very few people would have come to:

Dr. Kondracke: We had this this patient who had a large clot on his mitral valve. Literally the clot is flowing up into the atrium and back down into the ventricle with every heartbeat. It was quite unbelievable. You know, the likelihood of this moving was 100%. You know, with each beat, you know, the patient had been on heparin here and had a choice of surgical intervention or TPA. And that seems like a pretty easy choice to all of us. I mean, I, you know, you go with a TPA, you know, if you don’t want surgery, you at least give the TPA a try. It may not work, but you know, there’s sort of a 50/50 chance of it working. There’s 100% of you, if this clot moves, of you dying. There’s a very little chance that the Hepburn is going to completely dissolve it, but may stabilize it and surgery would probably work, but it’s surgery. So the patient had definitely said no surgery and the question of TPA was floating in the air, you know. And I think most of the doctors did not understand why he wouldn’t do TPA. I mean, it just, you know, it, it sort of blows your mind. Why would you with every heartbeat risk this clot moving in a massive stroke and, you know, and, and TPA is so simple to us, right. So he was able to recite all the person said, he said, no, I don’t want to do this. I don’t want to do it here. He was able to recite every single, uh, statistical, you know, difference that the surgeons had given him. He was able to recite what would happen to him, the, you know, the consequences of a massive stroke. And he wanted to go to, he wanted to go eight hours away to a hospital where he knew where his 11 family members lived in order to have this procedure. Yeah, he’s so, so he wanted, he wanted to chance this and go eight hours away. So you know, he had been in our hospital for you know, more than 24 hours on a heparin drip. So I didn’t really see any difference personally between staying here on a Heparin drip and getting a dose of Lovenox and having, you know, sort of a travel time. So in this case we were able to call the other hospital, have um, have a cardiologist on the other end, know that he would be admitted immediately. And he would be able to do the procedure or TPA at that hospital surrounded by his family were there to be anything go wrong. And so that’s an example of somebody who did have capacity and in a situation that most of us would not really be able to fathom why they would, right? And reason through each of those steps where at, where sort of a realistic person could understand.

Margot: We’ll finish off with one last example. This was a patient who was making a decision that seemed to be in line with values he had previously stood by, but was unable to demonstrate that he could reason properly:

Dr. Kondracke: So, so we have another case where a patient needed an antrectomy as an older guy had a CLL, had never wanted that treated before. He had an underlying history of homelessness, maybe schizophrenia. We weren’t really sure,  but we were able to talk to him about having an interactive meeting. He had several you know, several bleeding ulcers, repetitive transfusions, and it got to the point, you know, where we didn’t feel like we could keep up with this. Now patient was, you know, wanting to be DNR, did not want medical care, had not wanted medical care before.  did not want this surgery. He was able to sort of reason through all of these, uh, these things, you know, and, and everybody I think agreed that he had, he probably had capacity to refuse this. I mean, he had refused treatment for CLL in the past.  One of my astute fellows, sort of asked him. I mean, he, he, he did have some delusional thought process but really still didn’t want the surgery. And that was consistent in some ways with, with his life in the past. So, but, however, one of our fellows asked him the question of what would happen if you did have a surgery and his answers to that was that when he died, he would meet Hitler in hell. So all of a sudden the whole process changes because he actually, it has a psychotic reason for not having the surgery. And we were able to go through with the surgery.

Margot: This example demonstrates so much of what I find compelling about reasoning. Reasoning can be as intuitive as a patient leaving against medical advice to go take care of a family member or to pick up a welfare check. But reasoning can also be really challenging to assess, like when I see patients making decisions based on religious beliefs that I just don’t hold.

Now that we’ve discussed the 4 elements of the capacity evaluation, you may notice that there’s one big factor we haven’t talked about: the patient’s final decision. That’s because, to hijack a truism, capacity evaluations aren’t about the conclusion; they’re about the journey the patient took to get there. Patients are allowed to make decisions we disagree with, just so long as they get to that conclusion in a logical way. 

The flip side of that is true as well: We tend to scrutinize the capacity of patients who disagree, but agreeing too readily is actually also something to be suspicious of. If a patient goes along with a major surgery without asking any questions, it should tip you off that you might need to do a more thorough capacity evaluation. 

COMMON MYTHS AND MISCONCEPTIONS

Tamar: We wanted to spend the last few minutes diving into some misconceptions and common myths in capacity assessment. Firstly, just to circle back to what Jafar mentioned at the top of the episode: decision-making capacity is not universal. It’s time-dependent and it is decision-specific.

Dr. Kondracke: So oftentimes patients’ capacity changes and capacity about different things can be different, right? So a patient could have capacity to refuse, uh, you know, today’s blood draw, but not have capacity to make themselves DNR.

Tamar: And considering a patient’s capacity for each specific decision is especially important in patients with dementia or psychiatric diagnoses. Crucially, these patients do not uniformly lack decisional capacity. 

Dr. Kondracke: If a patient has dementia doesn’t mean they don’t 100% don’t have capacity. There are some decisions, again, that that patient may very well be able to make, say, and I would say the same with schizophrenia or a major mental illness. You know, if the patient, just because the patient has a psychotic disorder or thought disorder doesn’t mean they can’t understand getting a blood draw or getting an amputation or you know, having a cardiac cath or a cardiac surgery, you know. That they may very well be to weigh the risk and benefits, and be paranoid of a nurse, at the same time, or you know not necessarily of a nurse, but have paranoid thoughts too.

Margot: The next point we wanted to make is that capacity isn’t static. Sometimes patients wax and wane, so capacity needs to be re-assessed whenever there’s a change in a patient’s mental status. I once had a patient we needed to dialyze in order to understand his goals of care — and once his uremic encephalopathy cleared, he was able to tell us that he wanted to transition to hospice.

Tamar: A final thing that sometimes trips us up is the difference between capacity and competency. So as we’ve discussed, capacity is a clinical opinion made after a clinician evaluates whether a patient has the ability to make decisions about his or her healthcare. But competency is a legal decision, determined in court, and it’s usually a more large-scale comment on a person’s ability to execute any legal action, including things like signing a contract or standing trial. 

Dr. Kondracke: Competency, you know, is, is a judge saying this patient can’t make decisions for themselves. And it usually is because of a global, cognitive dysfunction. whether that be severe mental illness, you know, refractory mental illness, severe dementia, you know, uh, you know, patients with severe disabilities,  you know, uh, developmental disabilities, those are the patients often that have these, you know, these stipulations — lack of competency. Capacity is a, is really a medical term, you know that we use about, again, about a point in time and a point and procedure, you know.

PSYCHIATRY CONSULT

Jafar: We hope we’ve shown you a lot of the nuances and common pitfalls in the capacity assessment, and we want to make it very clear that you–yes, you, our clinician listener–have the capacity to assess capacity.  Try going through this process yourself using what we’ve been discussing today, and if you feel confident about it, that can be enough. Discuss it within your team, trade thoughts with a colleague, and feel empowered to make the call. It is not a sacred domain of psychiatrists to bless a patient with capacity. But of course you’re listening to this podcast about ethical dilemmas in medicine because, well, you know it’s not always an easy call to make. If you’re going through this and you’re still left wondering, your psychiatry consultants will be there to help you for those especially tough cases.

Dr. Kondracke: I think anytime there’s a question about capacity where people are unable to decide whether or not the patient has capacity, I think that’s a good place to get psychiatry involved because this is a fellowship. People spend a year learning how to do complicated capacity assessments. We may understand the nuances of this better than other people. We have a better understanding of the court process, we’re certainly willing to reach out to family members and get old history and, and all of those things may, may be helpful in the, in the process. How can we work best with a patient? Because most of the time the capacity assessments are not about whether or not the patient has capacity. It’s much more about how do we work with this patient to help them make the right decision, or the decision that might be life, life saving for them.

Jafar: Again, not everyone with a psychiatric diagnosis should have their decision-making capacity placed under suspicion. However, in those cases where a psychotic or mood disorder may be interfering with someone’s decision making capacity, a psych consult is not only important, but may actually be required by law in certain states.

Dr. Kondracke: So in New York state when you need it, you have to have a psychiatrist. If the patient’s capacity is thought to be secondary, lack of capacity rather is thought to be secondary to mental illness. So that’s, that’s where the state requires a second by a psychiatrist. So the first person who needs to see the patient as the attending of record, document capacity, and then a psychiatrist needs to be involved to assess the patient’s capacity.

Jafar: Ok ok, so now that you’ve decided that you need the help of a psychiatry consult, what’s the best way to call that consult? Having recently stepped into the role of a consultant myself, it is with deep earnestness that I beg all of you to be kind and thoughtful in this regard. Help them help you!

Seeing as capacity is time- and decision-specific, it only makes sense that you need a specific question. Exactly what procedure or decision are you trying to assess the patient’s capacity for?

Dr. Kondracke: So in terms of the consult, what you want to make sure you understand is what, what is the question? So oftentimes we’ll get, you know, we need a capacity assessment and you won’t know what kind of procedure they want to do. So, so you sort of going, well, what is it that you want the capacity for?

Jafar: Finally, always remember to keep your questions grounded in present realities.  

Dr. Kondracke: It’s not okay to have a theoretical capacity assessment. So for example, we may have to do this procedure in the future. Can you just ask them, you know, can you figure out if they have capacity and you’re like, I can’t do a capacity assessment for a procedure we’re not even offering.

CONCLUSION

Margot: To summarize, when you’re assessing a patient’s capacity, ask yourself these questions:

1. First, can my patient communicate a choice?
2. Second, can they understand the information I’m giving them?
3. Third, can they appreciate what this means for them?
4. And fourth, what does their reasoning structure look like?

It’s our responsibility as clinicians to address communication barriers and explain things in a way the patient can understand. We also need to reassess capacity frequently, because some patients wax and wane, and because capacity is time- and decision-specific.

Tamar: And now that we’ve covered some of the groundwork on the basics of capacity assessment, we want to leave you with a little teaser for what’s coming next. In our next At the Bedside episode, part II of capacity, we’ll be joined by Dr. Cindy Geppert, another expert on this topic, for a discussion of some especially difficult and ethically complicated cases. We hope you tune in, and we’ll see you then. 

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Jafar: Thanks for tuning in! We know these topics can stir up more questions than answers, and we look forward to hearing more about your experiences and reflections on assessing decision-making capacity. Please continue the conversation with us online at our facebook page, on twitter, or email us directly. Find show notes and contact information for us on our website: www.coreimpodcast.com/contact/

If you enjoyed listening to our show, and you’re able to communicate a choice, please give us a review on iTunes or whichever podcast app you use; it helps other people find us. We work hard on these podcasts so we’d really love to hear from you. Let us know what we are doing right and how we can improve. And as always, opinions expressed in this podcast are our own and do not represent the opinions of any affiliated institutions. 

Finally, special thanks to all our collaborators on this episode, our wonderful audio editor Julia Skubisz, our illustrator Michael Shen, endless technical support from Harit Shah, moral and executive support from Shreya Trivedi, and most importantly thanks to you, our listeners!

References

• Appelbaum, P. S. (2007). Assessment of patients’ competence to consent to treatment. New England Journal of Medicine, 357(18), 1834-1840.
• Charland, L. C. (2008). Decision-making capacity.
• Barstow, C., Shahan, B., & Roberts, M. (2018). Evaluating Medical Decision-Making Capacity in Practice. American family physician, 98(1), 40-46.