Determining Decision-Making Capacity in Older Adults: Part II

1. Determining Decision-Making Capacity in Older Adults: Part II

2. Geriatric Education Center of Michigan activities are supported by a grant from the U.S. Department of Health and Human Services, Health Resources and Services Administration, Public Health Service Act, Title VII, Section 753(a).

3. Learning Objectives • List scenarios where further decision-making evaluation may be required • Describe the referral process for a competency evaluation (mental capacity evaluation) • Discuss the components of a competency (mental capacity) evaluation

4. Major Capacity Domains • Independent Living • Financial Management • Treatment Consent • Testamentary Capacity • Research Consent • Sexual Consent • Voting • Driving

5. In a perfect world… We would ALL have durable power of attorney in place for medical and financial decisions

6. It’s an imperfect world…

7. When To Seek Further Evaluation • No Durable Power of Attorney (DPOA) • Patient decides to revoke DPOA • Only one physician or psychologist has deemed the individual mentally incapable • Concerns about patient’s decision making process

8. Helplines in Michigan To report suspected elder abuse, neglect, or exploitation in Michigan 1-800-996-6228 To reach Michigan Long Term Care Ombudsman 1-866-485-9393 http://www.ncea.aoa.gov/NCEAroot/Main_Site/Find_Help/State_Resources_Directory.aspx?state_id=mi

9. Conflicting Values • Democratic Value: Individual freedom for self-determination • Individual choice for matters pertaining to one’s self • Humanitarian Value: Protection from harm for individuals who make poor choices • “Poor” choices can include unreasonable, imprudent, unusual, or irrational choices

10. When Problems Become Evident • Inpatient Unit • Discharge planning • Outpatient • Sudden change in a patient you know well • Possible manipulation

11. Reasons to Be Involved • Safety concerns • Patient’s personal safety • Safe living environment • Treatment refusal • Legal issues • Abuse • Neglect • Treatment Planning

12. What to Do • Depends on your role & relationship • Referral • Provide specific referral question & background information • Obtain releases

13. Assessing Mental Capacity for Competence Evaluations • Appelbaum and Grisso (1988) • Identified four main criteria, which have become generally accepted & used as standards in legal proceedings • Expressing a choice • Understanding diagnostic and treatment-related information • Appreciation of consequences to situation • Reasoning to compare alternatives

14. Legal Standard 1: Can patient communicate a choice? Legal Standard 2: Does patient understand relevant information? Legal Standard 3: Does patient appreciate situation & consequences? Legal Standard 4: Can patient manipulate information rationally? Integration of Standards Can patient articulate the rationale for making the choice in reasonable, comprehensible way? Across time?

15. Mental Capacity Evaluations • Currently, no universally accepted, gold-standard instruments or measures to assess competency exist • Impaired findings on neuropsychological testing can support one’s case, but do not necessarily “seal the deal”

16. Physician • Primary care physician or other treating physician • Documentation is key • All 4 legal standards must be addressed • “pt incapable of making decisions” is not sufficient • When in doubt, seek a consultation

17. Neuropsychological Assessment for Cognitive Status • What is Neuropsychology? • Study of relationship between brain & behavior • What is a Neuropsychological Assessment? • Comprehensive, formalized cognitive and emotional assessment • Determines underlying organic etiology and/or psychogenic factors • When should I consult Neuropsychology? • Change in cognitive status • Determine presence of underlying organic etiology versus non-organic contribution

18. Neuropsychological Consult • If diagnosis is clear, full neuropsychological evaluation is not necessary • Psychologist needs experience in these types of evaluations

19. Instruments Designed Specifically for Mental Capacity Evaluations • Types of instruments • IADL-based on interview • IADL-based on performance • Performance-based measures designed specifically to assess need for guardianship and conservatorship

20. Review of Instruments Article • Assessing Decisional Capacity for Clinical Research or Treatment: A Review of Instruments (Dunn et al, 2006) • Identify limitations & strengths of standardized measures • Highlight need for more empirical research • http://ajp.psychiatryonline.org/cgi/content/full/163/8/1323#T2

21. Capacity to Consent to Treatment Instrument (CCTI) • Two vignettes • brain tumor • coronary artery blockage • Questions related to legal standards • comprehension of the information, • choices involved, pros & cons of * Norms available (for older adults)

22. Clinical Assessment • Whether or not formal measure is used, clinical interview is most powerful tool • Legal standards often can be assessed without formal measures • Cognitive and/or Mood/Personality testing can add supporting information

23. Legal Standard 1: Ability to Express Choice • This ability is a “threshold” • Being non-verbal does not negate this ability • The choice must be: • Stable (within reason –a “change of mind” can indicate increased awareness/ information) • Able to be implemented

24. Legal Standard 2: Ability to Understand Relevant Information • Determine whether patient understands condition • Assess retention of information or insight about condition • Assess comprehension of treatment options • Vignette tests can be helpful, but simple, verbatim repetition is not sufficient

25. Legal Standard 3: Ability to Grasp Situation and Consequences Comprehension is not the same as Appreciation • Must involve aforementioned abilities in relation to patient him/herself • Understand implications, basic meaning of disorder/diagnosis, & consequences

26. Legal Standard 4: Ability to Manipulate Information in a Rational, Reasonable Way • Can patient deliberate on the information and come to a decision that they can rationalize? • Scrutinize the patient’s reasoning  Scrutiny requires a level of objectivity

27. Maintaining Objectivity • Be very aware of own values/morals • Work hard at being objective even when you disagree with patient’s choices (e.g., freedom over safety)

28. Maintaining Dignity & Respect • Patients are human beings no matter what their cognitive status • Creative, self-agents, able to express feelings • Goal: maximize safety, independence, & autonomy, with the least restrictive methods

29. References Applelbaum & Grisso. (1991) Mentally Ill and Non-Mentally-Ill Patients' Abilities to Understand Informed Consent Disclosures for Medication: Preliminary Data. Law and Human Behavior, Vol. 15, 4, Aug, 1991. Assessment of Decision-Making Capacity in Older Adults: An Emerging Area of Practice and Research http://focus.psychiatryonline.org/data/Journals/FOCUS/1837/foc00109000088.pdf Assessment of Patients’ Competence to Consent to Treatment http://www.nejm.org/doi/pdf/10.1056/NEJMcp074045 http://www.sage-ereference.com/view/psychologylaw/n23.xml - “The Capacity to Consent to Treatment Instrument (CCTI)

30. Resources • Private practice • Check qualifications & reputation • For the People http://www.forthepeoplemi.com/ * not a law firm – some services will include legal fees