How is a capacity exam conducted?

How to Conduct a Capacity Assessment

A capacity assessment should evaluate four key abilities: understanding, appreciation, reasoning, and communication of choice specific to the decision at hand, with the thoroughness of evaluation increasing as risks increase and benefits decrease. 1

Presumption of Capacity

• All adults should be presumed to have capacity until proven otherwise 1
• Capacity assessment should be triggered by credible evidence that an individual may lack decisional capacity, not simply by a diagnosis 2
• Capacity is decision-specific and time-specific - a person may have capacity for some decisions but not others 2, 1

Components of Capacity Assessment

A structured approach to capacity assessment should evaluate whether the patient can:

1. Understand the information relevant to the decision
2. Retain that information long enough to make a decision
3. Use or weigh that information as part of the decision-making process
4. Communicate their decision by any means 2

Assessment Process

1. Prepare for the assessment:

   • Review relevant medical information
   • Choose an appropriate time when the patient is most alert
   • Ensure a quiet, private environment
   • Consider having an independent evaluator when risk is high 1

2. Explain the purpose of the assessment to the patient

3. Assess understanding:

   • Explain the relevant information in clear, simple language
   • Ask the patient to explain back in their own words:
     • Their medical condition
     • The proposed treatment/decision
     • Alternatives to the proposed treatment
     • Consequences of no treatment 3

4. Assess appreciation:

   • Determine if the patient recognizes how the information applies to their situation
   • Ask how they think the condition or treatment might affect them personally 3

5. Assess reasoning:

   • Ask the patient to explain their thought process
   • Evaluate if they can compare options and explain their choice
   • Determine if they can identify potential consequences 3

6. Assess ability to communicate a choice:

   • Confirm the patient can express a stable decision
   • Ensure the decision is not based on delusions or hallucinations 3

Assessment Tools

• The MacArthur Competence Assessment Tool (MacCAT) is one validated structured interview that can be used 2, 4
• Simple cognitive tests like the Mini-Mental State Examination (MMSE) alone are generally inaccurate for determining capacity 5

Special Considerations

• Fluctuating capacity: Assessment should occur during periods of optimal function when possible 1
• Temporary supports: Consider whether decision aids, simplified explanations, or involving trusted individuals might enhance capacity 1
• Risk-proportionate assessment: The rigor of capacity evaluation should increase as the risk of the decision increases and potential benefits decrease 2, 1

Common Pitfalls to Avoid

• Assuming lack of capacity based solely on diagnosis or age 2
• Determining incapacity because a patient makes an eccentric or unwise decision 2
• Failing to reassess capacity when it may fluctuate 1
• Not documenting the specific decision for which capacity is being assessed 3

When Capacity is Lacking

If a patient is determined to lack capacity:

• Identify a legally authorized representative (LAR) or surrogate decision-maker 2
• The LAR should respect the known will and preferences of the person 2
• If preferences cannot be ascertained, decisions should account for the person's beliefs, values, and welfare 2

Remember that capacity assessment is a complex process requiring clinical judgment and cannot be reduced to a simple screening tool 4.