Michael Levin

Dr. Otto
Geriatrics Clerkship
03.19.2019
Palliative EBM: Capacity
Capacity is super important! It comes up all the time in psychiatry. Did you know that patients
have to specifically consent to receive psychotropic medications, as if they were procedures?
It’s also a frequent reason psych consults are called. Almost all of these calls are unnecessary.
Any physician can determine capacity. It’s easier than you might think!

This table comes from a NEJM article from 2007. The principles laid down here are fairly
consistently endorsed as being sufficient. NOTE: A patient does not need to be alert and
oriented to time in order to have capacity. Question: Should we be including capacity
assessments in our physical exams more regularly? What about patients with higher education
and cognitive abilities, who might be very good at fooling us- does screening capacity have a
place?
There are several validated capacity assessment scales that provide a quantified measurement
of capacity. One in the public domain is called ACED, for Assessment for Capacity for Everyday
Decision-Making. Others are available for purchase. For the purposes of clinical practice, a
semi-structured interview, focusing on the above domains, will suffice.
Patients to consider making an evaluation of capacity include: those with neurodegenerative
disease, those with psychiatric disease, those with traumatic brain injury, adults hospitalized for
other reasons, and people approaching the end of their life.

Summary:
4 criteria for determining capacity---
1. Make a decision re: tx
a. Watch out for wavering
2. Understand situation= circumstances, consequences, treatment, alternatives, etc
a. This can be intellectual/factual
3. Understand the circumstances and consequences apply to them
a. Deep pathological denial = no capacity
4. Reason logically
a. Ask patient to explain how they weigh different options and why

Sources:
UpToDate. “Assessment of decision-making capacity in adults.” By Jason Karlawish. Literature
review current though Feb 2019. URL: https://www.uptodate.com/contents/assessment-of-
decision-making-capacity-in-adults#H2075085221

“Everyday decision-making ability in older persons with cognitive impairment.” By Lai JM et al.
in Am J Geri Psych, 2008 Aug; 16(8)693-6.

“Assessment of patients’ competence to consent to treatment. By Appelbaum, PS. In NEJM Nov

1 2007; 357:1834-1840.