From the Guidelines
To assess someone's capacity, ask questions that evaluate their understanding, appreciation, reasoning, and ability to communicate a choice regarding the specific decision at hand, as recommended by the most recent guidelines 1. Begin by explaining the decision they need to make and the relevant information. Then ask them to explain in their own words what decision they're facing, why they need to make it, what the options are, and what might happen with each option. Assess if they can explain the benefits and risks of different choices, why they prefer one option over others, and how their choice aligns with their values. Also determine if they can explain how the decision might affect their daily life and future. The questions should be tailored to the complexity of the decision - more complex decisions require more thorough assessment. Capacity is decision-specific and time-specific, meaning someone might have capacity for simple decisions but not complex ones, or might have capacity at certain times but not others. This approach respects autonomy while ensuring the person genuinely understands the decision they're making, as supported by recent studies 1. Additionally, consider using validated mental status tests, such as the Mini-Cog test, to assess multiple cognitive domains and identify potential cognitive impairment 1. It is also essential to consider the individual's own meaningful health outcome goals and care preferences, as emphasized in the Geriatric 5Ms framework 1. By following this approach, clinicians can ensure that the assessment of capacity is thorough, patient-centered, and respectful of the individual's autonomy, as recommended by recent guidelines 1.
Some key questions to ask during the assessment include:
- What is the decision you need to make?
- What are the options?
- What are the potential benefits and risks of each option?
- Why do you prefer one option over others?
- How does your choice align with your values?
- How might this decision affect your daily life and future?
- Can you explain the decision in your own words?
- Can you identify the key factors that will influence your decision?
These questions can help clinicians evaluate the individual's understanding, appreciation, reasoning, and ability to communicate a choice, and determine whether they have the capacity to make the decision at hand, as supported by recent studies 1.
From the Research
Assessing Capacity
To assess someone's capacity, the following questions can be asked:
- Can the person understand the relevant information about the decision they need to make? 2
- Can the person retain the information long enough to make a decision?
- Can the person use or weigh the information as part of the decision-making process?
- Can the person communicate their decision? 2
Decision-Specific Capacity
It is essential to note that capacity is decision-specific, meaning that a person may have the capacity to make one decision but not another 3. The complexity of the decision and the information involved can impact a person's capacity 2, 3.
Tools for Assessing Capacity
Several tools can be used to assess capacity, including:
- The Mini-Mental State Examination (MMSE) 4, 5, 6
- The Montreal Cognitive Assessment (MoCA) 5, 6
- The Aid to Capacity Evaluation (ACE) 4
- The Hopkins Competency Assessment Test 4
- The Understanding Treatment Disclosure 4
Clinical Guidance
When assessing capacity, clinicians should:
- Consider the decision-making process and document the outcome 3
- Reserve detailed assessments for situations where a major decision is needed and there is time to assess and discuss the assessment 3
- Not judge capacity based on the decision made, as an unwise decision is not evidence of a lack of capacity 3