Evidence-Based Reviews

Performing capacity evaluations: What’s expected from your consult

Current Psychiatry. 2014 January;13(1):41-44

References

1. Grisson T, Appelbaum PS. Assessing competence to consent to treatment—a guide for physicians and other health professionals. New York, NY: Oxford University Press; 1998.

2. Cohen LM, McCue JD, Green GM. Do clinical and formal assessments of capacity of patients in the intensive care unit to make decisions agree? Arch Intern Med. 1993;153(21): 2841-2845.

3. Farnsworth MG. Competency evaluations in a general hospital. Psychosomatics. 1990;31(1):60-66.

4. Sessums LL, Zembrzuska H, Jackson JL. Does this patient have medical decision-making capacity? JAMA. 2011; 306(4):420-427.

5. Cairns R, Maddock C, Buchanan A, et al. Prevalence and predictors of mental incapacity in psychiatric in-patients. Br J Psychiatry. 2005;187:379-385.

6. Candia PC, Barba AC. Mental capacity and consent to treatment in psychiatric patients: the state of the research. Curr Opin Psychiatry. 2011;24(5):442-446.

7. Duncan J. Common regions of the human frontal lobe recruited by diverse cognitive demands. Trends Neurosci. 2000;23(10):475-483.

8. Mandarelli G, Parmigiani G, Tarsitani L, et al. The relationship between executive functions and capacity to consent to treatment in acute psychiatric hospitalization. J Empir Res Hum Res Ethics. 2012;7(5):63-70.

9. Supady A, Voelkel A, Witzel J, et al. How is informed consent related to emotions and empathy? An exploratory neuroethical investigation. J Med Ethics. 2011;37(5):311-317.

10. Jeste DV, Depp CA, Palmer BW. Magnitude of impairment in decisional capacity in people with schizophrenia compared to normal subjects: an overview. Schizophr Bull. 2006;32(1):121-128.

11. Feldman-Stewart D, Brundage MD. Challenges for designing and implementing decision aids. Patient Educ Couns. 2004;54(3):265-273.

12. Charles C, Gafni A, Whelan T. Shared decision-making in the medical encounter: what does it mean? (or it takes at least two to tango). Soc Sci Med. 1997;44(5):681-692.

13. Appelbaum PS. Clinical practice. Assessment of patients’ competence to consent to treatment. N Engl J Med. 2007; 357(18):1834-1840.

14. Marson DC, McIntruff B, Hawkins L, et al. Consistency of physician judgments of capacity to consent to mild Alzheimer’s disease. J Am Geriatr Soc. 1997;45(4):453-457.

15. Kim SY, Caine ED. Utility and limits of the mini mental status examination in evaluating consent capacity in Alzheimer’s disease. Psychiatr Serv. 2002;53(10):1322-1324.

16. Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12(3):189-198.

17. Grisso T, Appelbaum PS. MacArthur competence assessment tool for treatment (MacCAT-T). Sarasota, FL: Professional Resource Press; 1998.

Physician bias has been identified in capacity evaluations. See Box 2.^4,10-12

Tools used in capacity evaluations

Most capacity evaluations are conducted by clinical interview (Box 3). The reliability of physicians’ unstructured judgments of capacity has been poor.¹³ In a study of 5 physicians who made a determination of capacity after watching a videotape of capacity assessments, the rate of agreement among the subjects was no better than that of chance.¹⁴

There is no specific, simple, quick test to assess capacity.

Folstein Mini-Mental State Examination. The MMSE has not been found to be predictive of decision-making capacity. It has been found to correlate with clinical judgments of incapacity, and may be used to identify patients at the high and low ends of the range of capacity, especially among older persons who exhibit cognitive impairment.¹⁵ Patients who have severe dementia (MMSE score <16) have a high likelihood of being unable to consent to treatment.¹⁶

MacArthur Competence Assessment Tool-Treatment. The MacCAT-T is a structured interviewing tool used to evaluate a patient’s decision-making ability. It is the most commonly used screening tool to evaluate decision-making capacity. Advantages of the MacCAT-T include a higher inter-rater agreement and—unlike other assessment instruments—its ability to incorporate information specific to a patient’s decision-making situation.¹⁷ The MacCAT-T requires training and experience to administer.

Bottom Line

Physicians make decisions about a patient’s decision-making capacity. Courts determine competence by a formal judicial proceeding. The psychiatric consultant’s role in capacity evaluations is to determine if the patient 1) possesses the requisite knowledge about the specific referral issue and 2) demonstrates a voluntary and reliable decision.

Related Resources

The MacArthur Treatment Competence Study. www.macarthur.virginia.edu/treatment.html.
Resnick P, Sorrentino R: Forensic considerations (chapter. 8). In: Psychosomatic medicine. Blumenfield M, Strain JJ, eds. Baltimore, MD: Lippincott Williams & Wilkins; 2006:91-106.
Appelbaum PS. Assessment of patients’ competence to consent to treatment. N Engl J Med. 2007;357(18):1834-1840.

Disclosure
Dr. Sorrentino reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Performing capacity evaluations: What’s expected from your consult

References

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