Capacity (Competence) Determination and Informed Consent

Capacity (Competence) Determination and Informed Consent is a topic covered in the 5-Minute Clinical Consult.

To view the entire topic, please or .

Medicine Central™ is a quick-consult mobile and web resource that includes diagnosis, treatment, medications, and follow-up information on over 700 diseases and disorders, providing fast answers—anytime, anywhere. Explore these free sample topics:

-- The first section of this topic is shown below --

Basics

  • Personal autonomy in decision making is a fundamental personal freedom.
  • Capacity determination is an inherent element of the informed consent process.
  • It is universally presumed that patients 18 years and older (or an emancipated minor under individual state laws) have legal and clinical capacity to give informed consent for health care testing, interventions, and treatment or to refuse same no matter the harm or benefit until proven otherwise.

Description

  • Capacity:
    • A clinical evaluation; determined by an authorized health care provider
    • Focuses on perceived ability of patient to participate in informed consent
  • Competence:
    • A legal determination of abilities, performed by a court judge
    • Involves medical information, but not limited to medical issues
  • Capacity is the currently preferred term to competence: Legal Capacity and Medical Capacity
  • A capacity determination is needed when arriving at a health care decision for testing, treatment, or an intervention involving risk of serious harm or no improvement.
    • Any treating health care provider can evaluate capacity, including the provider also obtaining informed consent or a psychiatrist or neuropsychiatric consultant
  • Medical capacity is determined by:
    • Clinical observation and response to questions
    • Capacity assessment tool(s)
    • Cognitive assessment tool
    • Interviews with a guardian or designated health care power of attorney (if indicated)
  • The four “C”s of capacity are:
    • Context: comprehension of their health status
    • Choices: able to describe options
    • Consequences: able to explain possible outcomes
    • Consistency: continuity of choice selection (1)[C]
  • Adequate cognition is a fundamental component, but not the sole determinant of capacity.

Epidemiology

Being near “end of life” increases the chance of having an advanced directive:

  • Among almost 800,000 U.S. adults studied, approximately 1/3 have completed an advanced directive (2).
  • As many as 1/3 of seriously ill geriatric patients near end of life do not have advanced directives (3).
Incidence

Need for capacity determination has been increased due to:

  • Increasing patient longevity
  • Prolonged chronic disease states
  • Better patient rehabilitation opportunities
  • Safer anesthetics and advanced postsurgery care
Prevalence

Prevalence varies based on the patient risk factors (pretest probability) and physician experience:

  • Only 2.8% of healthy outpatient seniors were found to lack capacity (4)
  • Among >3,700 geriatric hospital patients near end of life requiring health care decisions, only 30% demonstrated capacity to make those decisions (5).
  • Highest rate of incapacity is in patients with a learning disability.

Etiology and Pathophysiology

  • Dementia is the most likely cause for individuals to be found incapable of making health care decisions in the outpatient setting.
  • Capacity is a dynamic state; reassessment is necessary with each significant health care decision and informed consent

Risk Factors

  • For incapacity:
    • Longevity, multiple comorbidities, in hospital for medical reasons
    • Never married, never worked outside home
  • Insufficient informed consent:
    • Patient factors:
      • Health illiteracy
      • Language and cultural barriers
      • Excessive information
    • Provider factors:
      • Inexperience with process (e.g., house staff)
      • Insufficient discussion time
      • Use of medical terminology

General Prevention

Early assessment and periodic reassessment of capacity in:

  • Dynamic patient conditions, like electrolyte imbalance, closed head injuries, delirium states
  • After procedures with anesthesia or analgesics
  • Enhancement and dissipation of mind-altering substances

Commonly Associated Conditions

  • Dementia/Alzheimer disease, Parkinson disease, and traumatic brain injury
  • Schizophrenia, depression, and substance abuse
  • Acute illness, metabolic derangement

-- To view the remaining sections of this topic, please or --

Basics

  • Personal autonomy in decision making is a fundamental personal freedom.
  • Capacity determination is an inherent element of the informed consent process.
  • It is universally presumed that patients 18 years and older (or an emancipated minor under individual state laws) have legal and clinical capacity to give informed consent for health care testing, interventions, and treatment or to refuse same no matter the harm or benefit until proven otherwise.

Description

  • Capacity:
    • A clinical evaluation; determined by an authorized health care provider
    • Focuses on perceived ability of patient to participate in informed consent
  • Competence:
    • A legal determination of abilities, performed by a court judge
    • Involves medical information, but not limited to medical issues
  • Capacity is the currently preferred term to competence: Legal Capacity and Medical Capacity
  • A capacity determination is needed when arriving at a health care decision for testing, treatment, or an intervention involving risk of serious harm or no improvement.
    • Any treating health care provider can evaluate capacity, including the provider also obtaining informed consent or a psychiatrist or neuropsychiatric consultant
  • Medical capacity is determined by:
    • Clinical observation and response to questions
    • Capacity assessment tool(s)
    • Cognitive assessment tool
    • Interviews with a guardian or designated health care power of attorney (if indicated)
  • The four “C”s of capacity are:
    • Context: comprehension of their health status
    • Choices: able to describe options
    • Consequences: able to explain possible outcomes
    • Consistency: continuity of choice selection (1)[C]
  • Adequate cognition is a fundamental component, but not the sole determinant of capacity.

Epidemiology

Being near “end of life” increases the chance of having an advanced directive:

  • Among almost 800,000 U.S. adults studied, approximately 1/3 have completed an advanced directive (2).
  • As many as 1/3 of seriously ill geriatric patients near end of life do not have advanced directives (3).
Incidence

Need for capacity determination has been increased due to:

  • Increasing patient longevity
  • Prolonged chronic disease states
  • Better patient rehabilitation opportunities
  • Safer anesthetics and advanced postsurgery care
Prevalence

Prevalence varies based on the patient risk factors (pretest probability) and physician experience:

  • Only 2.8% of healthy outpatient seniors were found to lack capacity (4)
  • Among >3,700 geriatric hospital patients near end of life requiring health care decisions, only 30% demonstrated capacity to make those decisions (5).
  • Highest rate of incapacity is in patients with a learning disability.

Etiology and Pathophysiology

  • Dementia is the most likely cause for individuals to be found incapable of making health care decisions in the outpatient setting.
  • Capacity is a dynamic state; reassessment is necessary with each significant health care decision and informed consent

Risk Factors

  • For incapacity:
    • Longevity, multiple comorbidities, in hospital for medical reasons
    • Never married, never worked outside home
  • Insufficient informed consent:
    • Patient factors:
      • Health illiteracy
      • Language and cultural barriers
      • Excessive information
    • Provider factors:
      • Inexperience with process (e.g., house staff)
      • Insufficient discussion time
      • Use of medical terminology

General Prevention

Early assessment and periodic reassessment of capacity in:

  • Dynamic patient conditions, like electrolyte imbalance, closed head injuries, delirium states
  • After procedures with anesthesia or analgesics
  • Enhancement and dissipation of mind-altering substances

Commonly Associated Conditions

  • Dementia/Alzheimer disease, Parkinson disease, and traumatic brain injury
  • Schizophrenia, depression, and substance abuse
  • Acute illness, metabolic derangement

There's more to see -- the rest of this entry is available only to subscribers.