Mental Competency
- In a patient with a diagnosis that may increase the likelihood of cognitive and/or functional impairment (e.g., dementia, stroke, severe mental illness, head injury):
- Assess the patient’s level of competence in the context of the decision(s) that the patient needs to make, recognizing that higher-risk decisions require higher cognitive capacity
- Explain the purpose of the assessment and attempt to gain permission before you begin the assessment
- Include other professionals when appropriate
- In an otherwise well patient with subtle changes in function (e.g., family concerns, medication errors, repetitive questions, decline in personal hygiene):
- Perform an appropriate assessment of cognitive and functional abilities
- Refer for further assessment when necessary
- When a patient is making high-stakes care decisions (e.g., surgery/no surgery, resuscitation status) think about the need to assess their decision-making ability.
- When capacity assessment is required, actively assess the patient’s ability to understand, appreciate, reason, and express a choice.
- When impaired decision-making ability is identified, attempt to establish severity, reversibility, and duration in order to plan treatment and regular reassessment.
- When a patient refuses to participate in capacity assessment:
- Document their refusal
- Continue to engage in the provision of safe care that is acceptable to the patient
- Revisit the assessment when indicated
- Pursue the need for a substitute decision maker when necessary
General Overview
General Overview
- Mental capacity implies a clinical status established by a healthcare professional
- Capacity may change over time, and in the context of specific domains (medical, cognitive, functional)
- Mental competency refers to a legal status judged by a legal professional
- Situation-specific (care for self, sign out AMA, stand trial, sign a POA, change a will, financial decisions)
- May be competent to make care decisions but not financial decisions
- Situation-specific (care for self, sign out AMA, stand trial, sign a POA, change a will, financial decisions)
- For consent to be considered valid:
- Must be voluntary (without duress/coercion)
- Patient must have the mental capacity to consent
- Understands nature of proposed options, anticipated effect of options, and consequences of refusing
- Patient must be properly informed
- Diagnosis, proposed investigation/treatments, chance of success, alternatives, consequences of refusing
Assessment
Assessment
- Standardized screening tests for cognitive decline (MMSE, MoCA)
- Capacity and competence
- Clinical interviewing
- Understand information relevant to the decision
- Cognitive ability to remember the information long enough to make the decision
- Ask the patient to explain the nature of the condition/treatment/alternatives
- Cognitive ability to remember the information long enough to make the decision
- Appreciate the reasonably foreseeable consequences of a decision or lack of decision
- Weigh up information relevant to the decision
- Possible outcomes of treatment, alternatives, lack of treatment
- Realistic expectations
- Weigh up information relevant to the decision
- Communicate their decision – by talking, or any other means
- Understand information relevant to the decision
- Collateral information
- Further assessment (eg. Occupational therapy - on-road assessment, kitchen-cooking assessment)
- Clinical interviewing
- Advance Care directive (Living Will) prior to onset of impairment or early in progressive conditions
- Substitute decision maker
- If not assigned, by hierarchy:
- Guardian appointed by the court
- Power of Attorney for personal care
- Representative appointed by Consent and Capacity Board
- Spouse, common-law spouse or partner
- Child (if >16yo) or parent (custodial)
- Parent with right of access only (non-custodial parents)
- Brother or sister
- Any other relative
- Office of the Public Guardian and Trustee
- If not assigned, by hierarchy:
References:
- CMPA 2011. https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2011/is-this-patient-capable-of-consenting
- CMPA. https://www.cmpa-acpm.ca/serve/docs/ela/goodpracticesguide/pages/communication/Informed_Consent/three_key_elements-e.html
- CPSO 2007. https://www.cpso.on.ca/uploadedFiles/policies/policies/policyitems/capacity_consent_july07dialogue.pdf