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...
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.
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:
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):
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
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
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.
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