Psychosomatics 44:237-243, June 2003
© 2003 The Academy of Psychosomatic Medicine
Pitfalls in Assessment of Decision-Making Capacity
Linda Ganzini, M.D.,
Ladislav Volicer, M.D., Ph.D.,
William Nelson, Ph.D., and
Arthur Derse, M.D., J.D.
Received May 15, 2002; revision received Oct. 2, 2002; accepted Oct. 14, 2002. From the Mental Health Division, Portland Veterans Affairs Medical Center (VAMC); the Department of Psychiatry, Oregon Health and Science University; the Geriatric Research Education and Clinical Center, E.N. Rogers Memorial Veterans Hospital, Bedford, Mass.; the Veterans Health Administration National Center for Ethics in Health Care, New York; and the Center for the Study of Bioethics, Medical College of Wisconsin, Milwaukee. Address reprint requests to Dr. Ganzini, P3MHDC, Mental Health Division, Portland VAMC, P.O. Box 1034, Portland, OR 97207; ganzinil{at}ohsu.edu (e-mail).
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ABSTRACT
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A total of 395 consultation-liaison psychiatrists, geriatricians, and geriatric psychologists responded to a survey that asked them to rate the frequency and importance to clinical care of 23 potential pitfalls and misunderstandings by clinicians who refer patients for assessment of decision-making capacity. Respondents also indicated which pitfalls were the most important to address in educating health care professionals. Overall, 22 of 23 pitfalls were rated as common by more than half of the respondents. Thirty-six percent of the respondents indicated that the most important pitfall to address in educating health care professionals was the tendency for health care practitioners to assume that a patient who lacks capacity for one type of medical decision also lacks capacity for all medical decisions. The results suggest that additional education is needed to improve clinicians' ability to evaluate patients' decision-making capacity.
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INTRODUCTION
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Clinicians are charged with assessing patient's abilities to make a variety of decisions. For example, health care practitioners frequently must assess whether a patient has the capacity to refuse or to accept medical interventions and treatment. They may also play a role in assessing patients' abilities to decide to continue living independently, to leave the hospital against medical advice, to complete an advance directive, or to participate in research. Clinicians offer evidence to courts when patients are unable to handle their finances, require a conservator, or are so impaired in decision making and functioning that they require a guardian.
Clinicians must have a clear understanding of the concept of decision-making capacity to determine the extent to which patients can participate in such choices. The concept of decision-making capacity is complex and multidimensional, and there are no gold-standard instruments assuring its valid measurement.1 This study reports the results of a survey of three groups of clinicians—consultation-liaison psychiatrists, geriatricians, and geriatric psychologists—who were asked, on the basis of their experience, to rate the frequency of selected pitfalls (difficulties, misconceptions, misunderstandings, and knowledge deficits) in health care practitioners who refer patients for assessment of decision-making capacity. We also asked the respondents to rate how important these pitfalls were to patient care and to indicate the four most important pitfalls to address in educating health care professionals.
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METHOD
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Ten health care professionals, including consultation-liaison psychiatrists, geriatricians, internists, and clinical ethicists, were asked to provide a written list of common misunderstandings about capacity assessment that they had observed when assessing a patient's capacity at the request of other health care practitioners. In addition, we reviewed recent literature on competence and decision-making capacity and abstracted descriptions of misunderstandings noted by experts.1–8 We categorized these misunderstandings and developed a list of 23 potentially common and important pitfalls in capacity assessment (see Table 1 for examples of pitfalls). The survey was pretested with a convenience sample of 11 physicians and modified on the basis of their feedback.
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TABLE 1. Pitfalls in Health Care Practitioners' Assessment of Patients' Decision-Making Capacity Rated by Frequency, Importance to Patient Care, and Need to be Addressed in Professional Education, by Percentage of Survey Respondents (N=395)a
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The survey was sent to members of three professional groups: 1) all 658 U.S. psychiatrists who were members of the Academy for Psychosomatic Medicine, 2) 495 randomly selected U.S. geriatricians who were members of the Gerontological Society of America, and 3) 496 randomly selected U.S. psychologists who were members of the Gerontological Society of America. Each potential respondent was sent a copy of the survey and, if he or she did not respond, was sent a second copy 6–8 weeks later. The study was approved as exempt from the requirement for written informed consent by the Institutional Review Board of the Portland Veterans Affairs Medical Center.
The respondents were asked to return the questionnaire completed 1) if they worked in a setting where capacity assessments of adults commonly occurred, including a medical or surgical adult inpatient unit, an outpatient clinic, or a skilled nursing facility, and 2) if they had performed at least one capacity evaluation in the previous year at the request of another provider. Potential respondents who did not meet these criteria were asked to return the questionnaire uncompleted. Respondents were asked how many capacity assessments they performed in the last year, including assessments of the need for guardianship and of the capacity to make decisions about medical treatment, to leave the hospital against medical advice, to handle finances, and to live independently. Respondents were given the following instruction: "When asked by other health care practitioners to evaluate patient capacity, consultants sometime become aware of misconceptions and knowledge deficits on the part of the referring clinician. Some of these pitfalls and difficulties are described below. Please rate, among the pitfalls you may have observed, if these difficulties are rare, common, or very common. Then mark whether these difficulties are not very important, somewhat important, or very important for patient care." After rating the frequency and importance of each pitfall, the respondents were asked to choose four pitfalls (in no particular order) from among the list of 23 that they believed were the most important to address in educating health care professionals.
Responses are presented as frequencies and proportions. Professional groups were compared on categorical responses by using chi-square tests. In comparing the three respondent groups, alpha was adjusted for multiple comparisons by using the Bonferroni method and was set at 0.002 (0.05/23). All tests were two-tailed.
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RESULTS
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Fifty-three percent (875 of 1,657) of mailed surveys were returned, including surveys from 51% of the psychiatrists (N=335), 53% of the geriatricians (N=264), and 55% of the psychologists (N=276). However, 94 psychiatrists, 156 geriatricians, and 228 geriatric psychologists did not meet the inclusion criteria, because they had not performed a capacity assessment in the last year or did not work in a setting where capacity assessments in adults were common. As such, only 37% of the psychiatrists, 22% of the geriatricians, and 10% of the geriatric psychologists returned usable surveys; 395 surveys remained for analysis. The number of capacity evaluations per year varied among the respondent groups, with 51% (122 of 239) of the psychiatrists performing 21 or more capacity assessments per year, compared to 27% (29 of 106) of the geriatricians and 26% (12 of 46) of the psychologists ( 2=22.17, df=2, p<0.001).
Table 1 reports the frequency and importance to patient care of the 16 pitfalls that respondents indicated were most important to address in educating health care professionals. The pitfalls are ranked in descending order from the pitfall ranked by the largest proportion of respondents as one of the four most important for educating health care professionals to the pitfall ranked by the smallest proportion. The two pitfalls cited by the largest proportion as the most important for educating health care professionals were related to whether health care practitioners understood the assessment of decision-making capacity as decision specific: "Practitioner assumes that if the patient lacks capacity for one type of medical decision, the patient lacks capacity for all medical decisions," cited by 36% of respondents, and "Practitioner does not understand that capacity (or incapacity) is not ‘all or nothing’ but specific to a decision," cited by 35%. Fifty-nine percent (213 of 364) of respondents rated at least one of these two pitfalls as among the four most important.
Seven pitfalls were included among the most important to address in teaching health care professionals by fewer than 8% of respondents. These included 1) having negative feelings about the patient resulting in assessing the patient as lacking capacity, 2) assuming that committed patients lack capacity, 3) believing capacity is only relevant to decisions requiring informed consent, 4) assuming that if a patient has a conservator, he lacks capacity to make medical decisions, 5) failing to take into account positive feelings about the patient when assessing the patient's capacity, 6) believing that the primary purpose of informed consent is avoidance of malpractice litigation, and 7) failing to consider that a mental illness may be relevant to the patient's ability to make decisions. There were no differences among the respondent groups in the low ranking of these pitfalls. Despite these low ratings, all but one pitfall (number 7 in the previous list) were rated by more than half of respondents as common.
For five of the 16 pitfalls rated as important to address in educating health care professionals, there were significant differences between the three respondent groups in the proportion who included the pitfall as the most important (Table 2). Some of these differences may reflect differences in the populations for whom the professionals provide services—geriatric professionals included the pitfalls of equating dementia or cognitive impairment with lack of capacity as important to address in education, whereas mental health professionals rated the pitfall of equating schizophrenia with lack of capacity as the most important to address. Mental health professionals also included negative countertransferential feelings about the patient as leading to failure to recognize lack of capacity as important, where as geriatricians rated this pitfall as less important.
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TABLE 2. Pitfalls in Health Care Practitioners' Assessment of Patients' Decision-Making Capacity Rated as Most Important to Address in Professional Education, by Percentage of Survey Respondents in Three Disciplines (N=364)
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DISCUSSION
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The main finding of this survey was that the respondents, who were drawn from three groups of health care practitioners who perform capacity evaluations at the request of other clinicians, perceive that misunderstandings and knowledge deficits about the assessment of decision-making capacity are common. Of the 23 pitfalls about which we queried, 22 were rated as common by more than half of the respondents and the majority were rated as somewhat important to patient care. For the majority of pitfalls, there was agreement across respondent groups about the importance of addressing the pitfall in education of health care professionals.
Although decision-making capacity is variably defined, in general it reflects a patient's ability to communicate a choice and to understand and appreciate the consequences of decisions, particularly decisions about medical care.9 As noted by Grisso and Appelbaum,1 ethical and legal analyses offer little assistance with the practical task of distinguishing competent from incompetent patients, and the literature to guide clinicians is sparse, at times idiosyncratic, and of uncertain validity. The results of our survey may assist in prioritizing the important elements that should be the focus of educational efforts.
The three pitfalls identified by respondents as most important to address in education were related to the failure to distinguish general competence from specific capacity, including the lack of understanding that capacity or incapacity is not "all or nothing" but is specific to a decision (pitfall 2); the assumption that if the patient lacks capacity for one type of medical decision, the patient lacks capacity for all medical decisions (pitfall 1); and the confusion of legal competence, which is determined by a formal judicial proceeding, with decision-making capacity, which is determined by clinical assessment (pitfall 3). There were no statistically significant differences between respondent groups in the proportion who included these three pitfalls as important to address in education, suggesting broad agreement across respondents. If clinicians conceptualize a patient as globally lacking capacity, the patient is likely to not be allowed to make a variety of decisions that he/ she is actually able to make.
Two other related pitfalls pertained to physicians' obligations to ensure that patients obtain relevant and consistent information about the proposed interventions (pitfall 4) and to maximize the patient's capacity to make decisions (pitfall 13). Consistency may be a problem when many clinicians and consultants discuss an intervention or course of treatment with a patient. Presentation of information may vary on the basis of clinicians' knowledge, biases, and time constraints. Patients may require time to digest information about their options and goals and to consult with family and friends. Thus, what appears to be a lack of decision-making capacity may be, in fact, be the result of a communication barrier.1
A third concept that is important to address in education about decision-making capacity is that the process of engagement between the clinician and the patient is more important than the outcome. Pitfalls relevant to this concept include the health care practitioner's giving more weight to the patient's final decision than to the process used in coming to the decision (pitfall 7) and clinicians' failure to consider whether the patient lacks capacity if the patient agrees with the practitioner's recommendations (pitfall 5).
Respondents supported the idea that an understanding of the relationship between mental illness, cognitive ability, and capacity continues to elude clinicians. Neither a psychiatric diagnosis nor a score on a cognitive scale automatically determines decision-making capacity. For example, Grisso and Appelbaum10 reported that 23%–52% of patients with schizophrenia are impaired in medical decision making. Perhaps not surprisingly, when respondent groups disagreed about which were the most important pitfalls to address in educating clinicians, the disagreement most often reflected which disorders were most important to highlight in such education, with geriatric physicians emphasizing the importance of dementia and cognitive dysfunction (pitfalls 8 and 14) and mental health professionals emphasizing the importance of mental disorders and schizophrenia (pitfall 10).
Determinations of capacity may include assessment of both decisional autonomy (appreciation, understanding, judgment, and reasoning) and executional autonomy (ability to actually carry out a decision). In the case of ability to live independently, the patient must have the ability to understand the decision at hand, to perform in the environment, and to appreciate his/her limitations or special care needs. Thus, a decision about whether a patient can return to independent living requires more than just a bedside evaluation of the patient's understanding of the situation.11 Twenty-eight percent of respondents indicated that failure to take all of these elements into account is one of the most important pitfalls to address in educating health care professionals (pitfall 6). This congruence between decisional and executional autonomy is also important in determining other types of capacity such as capacity to handle finances.
We listed as a pitfall that the clinician fails to recognize that the criteria for determining capacity vary with the risks of the proposed intervention (pitfall 9). This pitfall refers to the sliding scale, a somewhat controversial way of using higher standards and thresholds for determining capacity as the risk of refusal of treatment increases.6,12,13 For example, a clinician might require a higher level of understanding and appreciation for an otherwise healthy person to decline cardiopulmonary resuscitation during a surgical procedure than would be required for a terminally ill person to refuse cardiopulmonary resuscitation. The major objection to the sliding scale is that it can allow the values of the clinician to potentially usurp the patient's choice, as clinicians may use a higher standard or threshold when the patient declines an intervention that the clinician recommends.7,14 Despite this controversy, clinicians find the sliding scale clinically useful and relevant and believe that the concept of the sliding scale should be taught to health care practitioners.
This study had several limitations. Slightly less than half of the potential respondents did not return the survey, and an even smaller proportion met the inclusion criteria. The frequency measurements (e.g., rare, common, very common) and measurements of the importance to patient care (not very, somewhat, or very important) were defined by neither the surveyors nor the respondents and therefore lacked precision. Because of these limitations, the validity of these measures might be questioned. Our method of measuring frequency, importance to clinical care, and importance for education, however, was consistent with our goals of determining perceptions of how common these pitfalls are and of prioritizing their importance in education.
In summary, despite an evolution and clarification of the concept of decision-making capacity in the mental health and ethics literature, clinicians who perform capacity evaluations perceive that misunderstandings about this concept are common and that they affect patient care. Educational efforts to improve understanding of decision-making capacity among medical trainees and practicing clinicians are warranted.
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ACKNOWLEDGMENTS
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The research was supported, in part, by the Veterans Health Administration (VHA) National Ethics Committee and the Department of Veterans Affairs Merit Review Program. The views expressed in this article do not necessarily represent the views of the Department of Veterans Affairs or of the United States Government. The authors thank the members of the VHA National Ethics Committee for assistance in developing the survey.
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REFERENCES
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- Grisso T, Appelbaum PS: Assessing Competence to Consent to Treatment. New York, Oxford University Press, 1998
- Gert B, Culver CM, Clouser KD: Bioethics: A Return to Fundamentals. New York, Oxford University Press, 1997
- Mahler J, Perry S: Assessing competency in the physically ill: guidelines for psychiatric consultants. Hosp Community Psychiatry 1988; 39:856-861[Abstract/Free Full Text]
- Gutheil TG, Appelbaum PS: Clinical Handbook of Psychiatry and the Law, 3rd ed. Philadelphia, Lippincott Williams & Wilkins, 2000
- Kapp MB: Medical treatment and the physician's legal duties, in Geriatric Medicine, 3rd ed. Edited by Cassel CK, Cohen HJ, Larson EB, Meier DE, Resnick NM, Rubenstein LZ, Sorensen LB. New York, Springer-Verlag, 1997, pp 979-992
- Karlawish JHT, Pearlman RA: Determination of decision making capacity, in Geriatric Medicine: An Evidence-Based Approach, 4th ed. Edited by Cassel CK, Leipzig RN, Cohen HJ, Larson EB, Meier DE. New York, Springer-Verlag, 2003, pp 1233-1241
- Lo B: Resolving Ethical Dilemmas: A Guide for Clinicians. Baltimore, Williams & Wilkins, 1995
- Moye J: Assessment of competency and decision making capacity, in Handbook of Assessment in Clinical Gerontology. Edited by Lichtenberg PA. New York, John Wiley & Sons, 1999, pp 488-528
- Appelbaum PS, Grisso T: Assessing patients' capacities to consent to treatment. N Engl J Med 1988; 319:1635-1638[Abstract]
- Grisso T, Appelbaum PS: The MacArthur Treatment Competence Study, III: abilities of patients to consent to psychiatric and medical treatments. Law Hum Behav 1995; 19:149-174[CrossRef][Medline]
- Department of Veterans Affairs: Assessment of Competency and Capacity of the Older Adult: A Practice Guideline for Psychologists. Milwaukee, Department of Veterans Affairs, National Center for Cost Containment, March 1997
- Buchanan AE, Brock DW: Deciding for Others: The Ethics of Surrogate Decision Making. Cambridge, UK, Cambridge University Press, 1989
- Drane JF: Competency to give an informed consent, a model for making clinical assessments. JAMA 1984; 252:925-927[Abstract]
- Beauchamp TL, Childress JF: Principles of Biomedical Ethics, 4th ed. New York, Oxford University Press, 1994
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ABSTRACT
INTRODUCTION
