UBC Objectives: Family Medicine, UBC Objectives: Mental Health, UBC Objectives: Care of the Elderly, UBC Objectives: Professional, Priority Topic: Dementia, & Priority Topic: Mental Competency

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to... 

• Assist the patient to express their own beliefs and values in solving ethical issues
• ​Exhibit ethical decision-making such as discussion of capacity of patients to make decisions
• Demonstrate an understanding of informed consent
• Assess mental competency
• Apply the key principles of the Mental Health Act, Personal Directive Act, and Adult Guardianship and Trusteeship Act
  
• Apply appropriate medical, ethical, and medico-legal frameworks to decision making

Dementia

Key Feature 6: In patients with dementia, assess competency. (Do not judge clearly competent patients as incompetent and vice versa.)
Skill: Clinical Reasoning
​Phase: Diagnosis

Mental Competency

Key Feature 1a: In a patient with subtle symptoms or signs of cognitive decline (ex: family concerns, medication errors, repetitive questions, decline in personal hygiene): Initiate assessment of mental competency, including use of a standardized tool.
Skill: Clinical Reasoning, Communication
Phase: History, Physical

Key Feature 1b: In a patient with subtle symptoms or signs of cognitive decline (ex: family concerns, medication errors, repetitive questions, decline in personal hygiene): Refer for further assessment when necessary.
Skill: Clinical Reasoning
Phase: Referral

Key Feature 2: In a patient with a diagnosis that may predict cognitive impairment, (ex: dementia, recent stroke, severe mental illness) identify those who require more careful assessment of decision-making capability.
Skill: Clinical Reasoning, Selectivity
Phase: Hypothesis generation, Diagnosis

Key Feature 3: When a patient is making decisions (ex: surgery/no surgery, resuscitation status) think about the need to assess their mental competency.
Skill: Clinical Reasoning, Professionalism
​Phase: Hypothesis generation

Key Feature 4: In a patient with cognitive impairment, identify intact decision-making abilities, as many may be retained.
Skill: Clinical Reasoning, Selectivity
Phase: Hypothesis generation, Treatment

{A bit of preamble context: Today was the first day of my one-month rotation at Three Bridges, a community health clinic with a mandate to serve patients who have been marginalised and underserved in traditional institutions of health care delivery. These may be patients with substance use disorders, without a fixed address, who are single teenage mothers, who are HIV+, who fall within the LGBTQ umbrella, etc.}

Three patients I met in clinic today prompted me to consider my ability to assess competency and highlighted my lack of confidence in knowing whether or not I could make the call regarding their decision-making capacity if I was the most responsible physician overseeing their care. One of these patients was an elderly gentleman with moderately severe major neurocognitive disorder (aka dementia) and melancholic depression. His therapy was clearly not optimised, and he was coping rather poorly, but yet he did not want to consider a change in therapy as was being suggested during the visit. I wondered if he was competent to make this decision. The second patient was a 19 year old transgender female (birth-assigned male) who wanted to initiate an application for genital surgery and appeared quite competent to make this decision based on my clinical assessment. But I was unsure of how exactly I could confirm - for a decision with as permanent of consequences as the one being requested - that it was a fully informed one. The third patient was a middle-aged man with a history of query bipolar disorder and alcohol use disorder who appeared hypomanic on assessment and not on any mood stabilisers. He was precontemplative as far as his alcohol use was concerned, with unrelenting alcohol consumption despite liver failure and a recent discharge from hospital for complications of heavy alcohol use. I wondered if he had capacity to make many of the decisions he was making on a day-to-day basis that were causing himself harm. 

So like a good little resident, I left clinic feeling motivated by the dejection of not knowing another whole chunk of how to be a doctor. As I walked home, I considered what I felt I would need to know to feel confident deciding one way or another if patients have decision-making capacity. When I sat down at home and flipped open my laptop to get to my notes on Capacity & Consent, all I found was a bare and anonymous paragraph that was certainly not my own composition: 

"For a patient to provide consent they must have the mental capacity or competency (legal equivalent) to provide consent, consent must be given voluntarily, must be informed and must apply to a specific act or set of acts. The ultimate responsibility for ensuring informed choice, mental capacity of the patient to provide consent, and documenting a valid consent rests with the caregiver proposing and providing the intervention."
-Anonymous 

How can I translate this into my day-to-day decision-making in the clinic when I need to know if the patient in front of me has the mental capacity to make a given decision, and how do I know what constitutes me giving enough information so that they can be sufficiently informed to provide informed consent?

According to UpToDate (2017), "In the absence of a reason to question an individual’s decision making, adults are generally assumed to have adequate capacity." Fair enough. So what are the reasons that ought to prompt me to question decision-making capacity? I read over the rest of the article, Assessment of decision-making capacity in adults (2017), and came up with a mnemonic I am going to call the 6Ds.

1. Dementia (moderate to severe)
2. Delirium
3. Delusion (psychosis)
4. Depression
5. Drug intoxication
6. Damage (brain)

Great! So now I know what patient factors ought to prompt me to think about assessing a patient's capacity when facing the need to make a decision that may impact their health. Now how do I go about assessing the patient's capacity? The UpToDate fairies have provided a succinct and superb table summarising the 4 domains that need to be assessed regarding any decision whenever there is any doubt about patient capacity, or even if there is no obvious reason to doubt patient capacity but the ramifications of the health decision are of increased significance (pay particular note to the instructions beneath the table).

What exactly are the "relevant facts" that must be disclosed to ensure consent is informed?

Per UpToDate (2017) paraphrasing, informed consent necessitates that:

1. The person received the information about the treatment that a reasonable person in the same circumstances would require to make a decision, including the
   1. Nature of the treatment
   2. Expected benefits of the treatment
   3. Material risks and side effects of the treatment
   4. Alternative courses of action
   5. Likely consequences of not having the treatment
2. The person was offered access to resources with more information about the treatment and received responses to his/her requests for additional information about the treatment

Legally, there are 3 ways in which the courts may decide that a physician has followed through on their duty to inform when obtaining consent regarding a treatment or other medical decision. Considering all 3 of these standards can help provide clarity when considering, for a given medical decision, wether all of the reasonably relevant facts have indeed been disclosed for the decision at hand. Per Informed procedural consent (UpToDate, 2017):

1. Professional Standard: The professional standard of care requires that a physician must disclose those facts that a reasonable physician who was faced with this particular set of circumstances would disclose.
2. Objective Patient-centered Standard: The physician must disclose those facts that a reasonable patient in a similar situation would need to know in order to make an informed choice.
3. Subjective Patient-centered Standard: The subjective standard for disclosure requires the physician to relay facts that a particular patient deems important in the decision-making process.

Although I cannot now retroactively seek answers from the patients I encountered today to determine their decision-making capacity, I believe my new approach (see below) based on the above information can provide me with the guidance to determine future patients' decision-making capacity moving forward. I am certain I will have many opportunities to put this to the test. 

Madalena's (aka UpToDate's) Decision-making Capacity Framework

1. Is there a decision that needs to be made that can affect the patient's health?
2. Are any of the 6Ds present that would prompt me to consider whether the patient lacks the capacity to make such a decision? Capacity in an adult is otherwise assumed.
3. Consider the importance of the decision that needs to be made, and if the repercussions of the decision are significant, consider assessing the patient's capacity to make the decision even if none of the 6Ds are present.
4. Assess capacity to make the decision if indicated:
   1. Ask the patient to explain to you their understanding of the facts you explained to them
   2. Ask the patient what choice they want to make given the facts
   3. Ask the patient what they believe are the benefits and risks of this choice as it applies to themselves 
   4. Ask the patient to explain why they think the benefits and risks of this choice outweigh those of the other options
5. If patient appears capable, feel confident that they have the capacity to make the decision at hand and proceed with this option. If the patient does not appear capable, consider the need for a formal capacity assessment by a second health care provider. In emergency situations or when a patient already has documentation incompetency, defer to the substitute decision maker (certainly the topic of another blog post). If the patient is deemed to lack capacity, remember that this may apply to a specific type of decision-making domain (ex: the patient may not have the capacity to manage their own chequebook, but they may retain the ability to make personal health care decisions).
6. Disclose the relevant facts:
   1. Nature of the treatment
   2. Expected benefits of the treatment
   3. Material risks and side effects of the treatment
   4. Alternative courses of action
   5. Likely consequences of not having the treatment
7. Consider the facts that have been disclosed in relation to the physicians' legal duty to inform, and provide any other information that may be relevant to making the decision, if indicated. 
8. Provide the opportunity for answering any questions the patient may have, and offer resources to further support the decision at hand
9. Document:
   1. Date and time
   2. Who was present
   3. What was discussed (relevant facts)
   4. A summary of the capacity assessment (that the patient understood the concepts as discussed and agreed to proceed, with further details of this assessment as warranted by the significance of the decision).
   5. In addition, the physician should document that the patient was offered/provided with appropriate literature, that the patient had the opportunity to ask questions, and that those questions were answered.

This all seems like a lot of work, but in practice I imagine it could be done rather efficiently with a bit of practice. And regardless, it is important to put in the work because this is just the ethical thing to do. As UpToDate (2017) summarises: 

"The benefits of truly informed consent include

• Protecting the patient's right of self-determination
• Engaging the patient in his or her health care
• Enhancing the physician-patient relationship
• Encouraging physicians to thoroughly review the patient's therapeutic options
• Reducing discontent and litigation when there are complications"

In summary
"For a patient to provide consent they must have the mental capacity or competency (legal equivalent*) to provide consent, consent must be given voluntarily, must be informed and must apply to a specific act or set of acts. The ultimate responsibility for ensuring informed choice, mental capacity of the patient to provide consent, and documenting a valid consent rests with the caregiver proposing and providing the intervention."
-Anonymous

*Legal competency decisions are set out by law, in such acts as the Mental Health Act and the Personal Directive Act and Trusteeship Act (actual name varies but with the same idea), which vary provincially in Canada.