What is the process for determining a patient's mental competence to appoint a power of attorney (POA)?

From the Guidelines

To determine a patient's mental competence to appoint a power of attorney (POA), a comprehensive assessment of their cognitive and psychological health is necessary, as outlined in the most recent guidelines from the Mayo Clinic Proceedings 1. This assessment should begin with a formal evaluation, including a review of the patient's medical history, a mental status examination, and a discussion of the implications of appointing a POA. The patient's understanding of the concept of POA, their ability to identify a chosen representative, and their comprehension of the authority they are granting should be thoroughly assessed.

Key aspects of the assessment include:

• Evaluating the patient's cognitive status, orientation to person, place, and time, and their ability to understand relevant information
• Assessing the patient's memory, judgment, reasoning abilities, and absence of delusions or hallucinations that might impair decision-making
• Utilizing standardized cognitive assessments, such as the Mini-Cog test, which has a sensitivity of 76% and specificity of 89% for identifying people with possible dementia 1
• Considering the patient's ability to appreciate the situation and consequences, reason about options, and communicate a choice

The Alzheimer's Association clinical practice guideline for the diagnostic evaluation, testing, counseling, and disclosure of suspected Alzheimer's disease and related disorders also emphasizes the importance of a comprehensive assessment, including a mental status examination and a dementia-focused neurologic examination 1.

In accordance with the Mental Capacity Act 2005, the assessment should presume that every adult patient has the capacity to make decisions about their care and treatment, and the patient's wishes, including any advance decisions, should be taken into account 1. If there is doubt or disagreement about an advance decision's existence, validity, or applicability, the case should be referred to the Court of Protection 1.

Ultimately, the assessment should conclude with a professional opinion that the patient possesses decision-making capacity specifically for the purpose of appointing a POA, based on the most recent and highest-quality evidence available 1.

From the Research

Determining Mental Competence for Appointing a Power of Attorney (POA)

The process for determining a patient's mental competence to appoint a power of attorney (POA) involves several steps and considerations.

• Recognizing the conditions that require a competence assessment is the first step, as outlined in the study by 2.
• A full evaluation of the patient's competence is necessary, taking into account their ability to understand, reason, and make decisions 2.
• The degree of competence should be correlated with the complexity of the decision, such as appointing a POA 2.
• Improving the patient's competence when possible is also an important consideration 2.
• Establishing who will make the decision if the patient is deemed incompetent is a crucial step in the process 2.

Assessment Tools and Methods

Various assessment tools and methods can be used to evaluate a patient's mental competence, including:

• The Mini-Mental State Examination and the Mini-Cog, which are proprietary and open-source clinical examination tools 3.
• The mental status examination, which includes general observations and specific testing of cognitive functions such as attention, executive functioning, and memory 3.
• Nurse-led assessments, which may involve informal, intuitive, and holistic processes that combine physiological and mental capacity status 4.

Importance of Clinical Judgment

Clinical judgment is necessary in selecting the most appropriate assessment tool and interpreting the results 3.

• The mental status examination should be interpreted in the context of physician observation, and there are no guidelines to direct further testing in the setting of an abnormal mental status examination 3.
• The quality of the evidence regarding cognitive training and cognitive rehabilitation for patients with dementia is limited, and further well-designed studies are required to obtain more definitive evidence 5, 6.