How can you determine if a patient is competent to make medical decisions?

Determining Patient Competence for Medical Decision-Making

To determine if a patient is competent to make medical decisions, clinicians must assess four key abilities: understanding, appreciation, reasoning, and the ability to communicate a choice. 1

Core Principles of Capacity Assessment

• Presumption of capacity: Adults are presumed to have decision-making capacity until demonstrated otherwise 1
• Decision-specific assessment: Capacity is issue-specific; patients may have capacity for simple decisions but not complex ones 1
• Fluctuating capacity: Assessment should be timed appropriately as capacity may fluctuate throughout the day 2
• Proportionate assessment: The depth of assessment should be proportionate to the risks involved in the decision 2

Structured Assessment Framework

Step 1: Identify When Formal Assessment Is Needed

• Refusal of clearly beneficial treatment
• Acceptance of high-risk procedures without consideration
• Acute change in mental status
• Presence of cognitive impairment
• High-risk decisions with significant consequences 3

Step 2: Assess the Four Core Elements of Capacity

1. Understanding

   • Ask the patient to explain in their own words:
     • Their medical condition
     • The proposed treatment/intervention
     • Alternative options (including no treatment)
     • Risks and benefits of each option 1, 3

2. Appreciation

   • Determine if the patient acknowledges:
     • That they have a medical condition requiring decision
     • The probable consequences of treatment options
     • How the information applies to their personal situation 1

3. Reasoning

   • Evaluate the patient's ability to:
     • Compare options using personal values
     • Provide logical reasons for their choice
     • Demonstrate consistent reasoning process 1, 3

4. Communication of Choice

   • Verify the patient can:
     • Express a clear and consistent choice
     • Communicate their decision by any means available 2

Step 3: Document the Assessment

• Record specific questions asked and patient's responses
• Note observations about patient's cognitive state
• Document reasoning for capacity determination
• Include who was present during assessment 3

Common Pitfalls to Avoid

• Diagnosis-based assumptions: A diagnosis of dementia or psychiatric illness does not automatically mean lack of capacity 1, 2
• Unwise decisions: A patient should not be deemed incapable merely because they make a decision that appears unwise to clinicians 1
• Reliance on cognitive tests alone: Mini-Mental State Examination scores do not directly correlate with decision-making capacity 2
• All-or-nothing judgments: Avoid making sweeping determinations about a person's overall competence 1

Special Considerations

• Supported decision-making: Patients cannot be treated as lacking capacity unless all practicable steps to support them have been taken without success 1
• Temporary impairments: Consider whether capacity is affected by temporary factors (medication effects, delirium, intoxication) that may resolve 1
• Psychiatric consultation: Consider psychiatric consultation for complex cases, though the treating physician makes the final determination 3

When Capacity Is Lacking

• Identify an appropriate surrogate decision-maker 1
• For previously competent adults, decisions should align with:
  1. Previously stated treatment preferences if applicable
  2. What the patient would likely choose if able to speak
  3. The patient's best interests 1

Remember that capacity assessment is not about the specific decision made, but rather the process by which the patient arrives at that decision. A structured, systematic approach to capacity assessment ensures respect for patient autonomy while providing appropriate protection for those who truly lack decision-making capacity.