Patient Capacity in Clinical Practice: More on Assessment Pearls

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In the first installment of this Clinician Commentary, we discussed the definitions of capacity versus competence, risk factors for changes in capacity for medical decision making, and the pillars of capacity to consider. Now, let’s examine specific tools for physicians and what actions to take if a patient’s capacity seems diminished.

Formal Capacity Assessment Tools

Any physician (not limited to psychiatry specifically) can evaluate capacity using a directed clinical interview as described in the first article (link). With that said, there are many formal capacity assessment tools to additionally aid in the assessment of capacity. These include the Aid to Capacity Evaluation (ACE), Hopkins Competency Assessment Tool (HCAT), Understanding Treatment Disclosure, and the MacArthur Competence Assessment Tool for Treatment (MacCAT-T).^1–5
 
If a directed clinical interview does not clearly demonstrate a patient’s capacity, then the next step would be for the treating physician to utilize one of these formal capacity assessment tools. These tools allow the assessor to ask questions that assess the patient's understanding, appreciation, and reasoning regarding treatment decisions, and objectively allows the assessor to document the results.
 
Let us consider the MacArthur Competence Assessment Tool for Treatment (MacCAT-T). The MacCAT-T utilizes a semi-structured interview to guide the clinician through an assessment of the patient’s understanding, appreciation, reasoning, and ability to express a choice. With the MacCAT-T, appreciation is assessed in 2 categories: whether there is “any reason to doubt” the diagnosis, and whether the treatment “might be of benefit to you (the patient).” Reasoning assessment takes place through questions considering how patients compare treatment choices and consequences and apply treatment choices to everyday situations. The MacCAT-T utilizes information directly from the patient’s chart in order to make the test personally relevant and customized to the patient. The patients receive scores of either “adequate,” “partial,” or “inadequate” capacity ratings for each item. There is a score for each ability (understanding, reasoning, and appreciation), but no overall score or cutoff scores for any of the abilities. The MacCAT-T was not developed to determine global competence, but rather is utilized to identify specific areas of relative capacity or incapacity, and is to be interpreted in the context of other relevant clinical information.^1–5

What to Do When a Patient Lacks Capacity

Physicians across all specialties possess the ability to evaluate capacity. A formal consultation to psychiatry isn't obligatory to ascertain a patient's lack of capacity for medical decision-making. Nonetheless, in cases of uncertainty despite use of formal assessment tools, referring to psychiatry for further evaluation is an option. With that said, some might argue that presence of uncertainty answers the question and indicates impaired patient capacity.
 
After establishing that a patient lacks capacity, the physician should address reversible causes of impairment or determine an appropriate surrogate decision maker. The response to identified impaired capacity varies based on factors like duration and severity of impairment, and the gravity of the medical decision. Unless immediate action is necessary due to the patient's medical urgency, efforts should prioritize identifying and rectifying any reversible causes of impairment. This holds significance for hospitalized patients experiencing impaired capacity due to delirium, as treating underlying causes may reinstate decision-making ability.
 
In cases where impairments are not reversable, seeking a substitute decision-maker becomes an ethical imperative. Ideally, these surrogates would have been designated by the patient beforehand. In the absence of a designated surrogate, laws vary from state to state on who can serve in this role, typically prioritizing the spouse followed by adult children, then parents, then siblings and lastly other relatives.
 
Pursuit of formal guardianship may become necessary when a clinician faces significant treatment dilemmas involving an incapable patient without an available health care surrogate or next of kin. A judge will assign a guardian in a court of law after determining the patient's decisional incompetence. Guardianship might also be necessary when first-degree relatives cannot agree on medical care decisions or if the next of kin prioritizes self-interest over the patient's best interests.

In Conclusion

Podiatric physicians likely inherently make decisions about patient capacity on a daily basis when discussing treatment options and recommending surgical interventions. The objective of this review was to provide a deeper understanding of capacity evaluation in more challenging clinical situations in which this assessment is not as apparent.
 
Dr. Joseph is a resident of the Temple University Hospital Podiatric Surgical Residency Program in Philadelphia. 
 
Dr. Fils-Aime is a resident of theTemple University Hospital Podiatric Surgical Residency Program in Philadelphia.
 
Dr. Meyr is a Professor in the Department of Surgery at Temple University School of Podiatric Medicine in Philadelphia.

References

1.    Sturman E. The Capacity to consent to treatment and research: A review of standarized assessment tool. Clin Psych Rev. 2005; 25:954-974.
2.     Grisso T, Appelbaum PS, Hill-Fotouhi C. The MacCAT-T: a clinical tool to assess patients' capacities to make treatment decisions. Psychiatr Serv. 1997;48(11):1415-1419. doi:10.1176/ps.48.11.1415
3.    American medical Association. Principles of Medical Ethics. 2009.
4.    Charles L, Brémault-Phillips S, Pike A, et al. Decision-making capacity assessment education. J Am Geriatr Soc. 2021;69:E9–E12.
5.     Lamont S, Jeon YH, Chiarella M. Assessing patient capacity to consent to treatment: an integrative review of instruments and tools. J Clin Nurs. 2013;22(17-18):2387-2403. doi:10.1111/jocn.12215