Who determines a patient's competency, an Advanced Practice Registered Nurse (APRN) such as an Adult-Gerontology Acute Care Nurse Practitioner (AGACNP), an attending physician, a judge, or the next of kin?

Determination of Patient Competency

The determination of a patient's competency comes from a judge, not from healthcare providers or family members. 1, 2

Legal Framework for Competency Determination

• Competency is a legal determination that can only be made by a court of law, typically by a judge, after reviewing evidence of the patient's decision-making abilities 1
• The law presumes all adults have competency until proven otherwise through legal proceedings, regardless of their medical diagnosis or condition 2
• Healthcare providers may assess decision-making capacity, but this clinical assessment is distinct from the legal determination of competency 1

Understanding Decision-Making Capacity vs. Competency

• Decision-making capacity is a clinical determination made by healthcare providers that evaluates a patient's ability to make specific healthcare decisions 1
• Capacity assessment evaluates four key abilities: understanding relevant information, retaining that information, using or weighing information to make decisions, and communicating the decision 2
• Capacity is decision-specific, meaning a patient may have capacity for some decisions but not others 2
• The AGACNP or attending physician may assess and document a patient's decision-making capacity, but cannot legally determine competency 1

Role of Healthcare Providers in Capacity Assessment

• Healthcare providers, including AGACNPs, are responsible for assessing and documenting a patient's decision-making capacity for specific medical decisions 1
• This assessment should include evaluating the patient's ability to understand information about the decision, retain that information, use the information in the decision-making process, and communicate their decision 1
• When documenting concerns about capacity, providers should include specific examples of the patient's impairment rather than making vague statements 1

Role of Family Members

• Next of kin or family members cannot determine a patient's competency 2
• However, family members may provide valuable information about the patient's baseline cognitive function and previously expressed wishes 1
• If a patient is deemed incompetent by a court, family members may be appointed as legal guardians or surrogate decision-makers 1

Common Pitfalls to Avoid

• Confusing decision-making capacity (clinical determination) with competency (legal determination) 1, 2
• Assuming that a diagnosis, age, or appearance alone can determine capacity or competency 1
• Making global assessments of incapacity without specifying which decisions the patient cannot make 1
• Failing to reassess capacity when a patient's condition may improve 1

Ethical Considerations

• Healthcare providers should attempt to include patients in discussions to the extent possible, even when capacity is impaired 2
• Inappropriate determination of incapacity can lead to unnecessary restrictions on patient autonomy 2
• Balancing respect for patient autonomy with protection of patient well-being is essential in capacity assessments 1, 2