The document discusses the critical aspects of assessing medical decision-making capacity, highlighting the prevalence of incapacity among elderly patients and the role of clinicians in recognizing this issue. It outlines the specific and dynamic nature of medical capacity, requirements for evaluation, and the importance of surrogate decision-makers. Additionally, it provides tools for capacity assessment and emphasizes that patients with decision-making capacity have the right to refuse treatments.

1. Determining Medical Decision
Making Capacity &
Surrogate Decision Makers
Presented by
Andrea Chatburn, DO, MA
Medical Director for Ethics
8.4.2015

2. www.providence.org/ethics

3. Why is determining capacity
important?
• Clinicians regularly fail to recognize incapacity
• Review of 43 high-quality prospective studies evaluating
medical decision-making capacity found:
• 2.8% of Healthy Elderly control patients in
community lacked capacity
• 26% of Elderly Medicine Inpatients lacked
capacity
• Physicians recognized incapacity only 42% of
the time
Sessums, L. et al., Does this Patient Have Medical Decision-Making Capacity? JAMA 206; 4.
2011.

4. Why is determining capacity
important?
• ANY physician can make a determination of
incapacity for medical decision making, not
just a psychiatrist
• Risk of poor communication skills:
– Pseudo-incapacity occurs when the patient is
provided information in a way they cannot
understand.
– Ex: excessive medical jargon
– English as Second Language
Sessums, L. et al., Does this Patient Have Medical Decision-Making Capacity? JAMA 206; 4.
2011.

5. Not going to cover
• Evaluation of capacity in patients with:
– Active suicidal ideation
– Severe Acute Psychosis
– Participation in Research study

6. Competence- Legal
 Adults assumed competent
 Incompetence determined by a court
 Global- unable to make any decisions
 Need for referral to attorney with goal of
naming a Guardian ad Litem  Guardian

7. Capacity- Medical
Capacity is both specific and dynamic.
 Specific Question
 Specific Time
 Dynamic- can change based on time and
question

8. Capacity- Medical
Requirements for Medical Decision Making
Capacity:
 Choose & Communicate that Choice
 Must understand relevant information &
appreciate medical consequences
 Teach back
 Reason Through Options- Risks/Benefits
 Consistent with known values

9. CURVES Mnemonic
 Choose & Communicate
 Understand
 Reason
 Value
 Emergency
 Surrogate

10. Annas & Densenberger’s
5 Questions
1. What is your present condition?
2. What treatment is being recommended to
you?
3. What might happen to you if you decide to
accept the proposed treatment?
4. What might happen to you if you decide to
forego the proposed treatment?
5. What alternative are available and what are
the consequences of each?

11. .phccapacityquestions

12. Additional Validated Tools
• Clock Drawing Test
• ACE- Aid to Capaity Evaluation
• MMSE <24/30 indicates delirium or dementia
• MDAS (Memorial Delirium Assessment Scale)
• MacArthur Competence Assessment Tool for
Treatment (MacCAT-T)
• CAM- Confusion Assessment Scale

13. Low Risk High Risk
Capacity Spectrum
• Less invasive
• Less detailed
• Less teach back
• More invasive
• More detailed
• Complex teach back

14. WA Surrogate Hierarchy
 Guardian
 Durable Power of Attorney – HC
 Spouse or Registered Domestic Partner
 Adult Children
 Living Parents
 Adult Siblings

15. .phcsurrogatehierarchy

16. Surrogate Decision Makers
 Must be available
 Expected to use Substituted Judgment
 Choosing what the patient would choose
 Look to Advance Directive
 Look to POLST & context
 Patient’s previously stated wishes

17. Implied Consent
 Patient unable to express preference
 No surrogate available
 Acute- Immediate action required to:
 Save Life or Save Limb
 Reasonable person (non-experimental)

18. .phcimpliedconsent

19. Refusal of interventions:
Patients who have medical decision
making capacity are allowed to be
refuse recommended medical
interventions and make what may
seem like unreasonable or even
harmful choices.5

20. Patients with diminished capacity

23. Bibliography
1. Appelbaum, P. Assessment of Patient’s Competence to Consent to Treatment. NEJM. 357;
18. 2007.
2. Chow, G. et al., CURVES: A Mnemonic for Determining Medical Decision-Making Capacity
and Providing Emergency Treatment in the Acute Setting. CHEST. 137(2). 2010.
3. Sessums, L. et al., Does this Patient Have Medical Decision-Making Capacity? JAMA 206;
4. 2011.
4. Sulmasey, D. and L Snyder. Substituted Interests and Best Judgments. JAMA. 304; 17.
2010.
5. Soriano, M. and R. Lagman. When the Patient Says No. American Journal of Hospice &
Palliative Medicine. 29(5) 401-404.
6. United States Conference of Catholic Bishops Ethical and Religious Directives for Catholic
Health Care Services. 5th ed.
7. www.wsma.org/POLST
8. http://www.honoringchoicespnw.org/
9. www.capc.org/fastfacts