Capacity v. Competency and Why it Matters
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Evaluating medical decision-making capacity can be challengingwhentreatingpatients whoexhibit cognitive deficits.Understanding the physician’s role in assessing capacity versus the judicial determination of incompetence can makea significantdifference in how these situationsshould beapproached.
Inhealthcare, medical decision-makingcapacityrefers to “an individual’s ability to understand the significant benefits, risks, and alternatives to proposed health care and make and communicate a healthcare decision” (Uniform Health Care Decisions Act of 1993).Medical decision-making capacity is specific to the proposed medical intervention,anditcan change over time.Incompetenceis a legal term thatrefers to an enduring general inability to make valid decisions. This is established by a judge or magistrate,and it is reserved for individuals who are presumed to be permanently and markedly impaired.Ultimately,physicians make decisions about a patient’s medical decision-making capacity;courts determineincompetence.Because capacity and competency are not interchangeable,physiciansshouldbe sure to use correct terminologywhendocumentingin patients’medical records.
In 2004 a study completed by Kings College in London estimated the prevalence of mental incapacity in medical inpatientsto benearly 40%, yet only 24% of the patients were identified as lacking capacityby the medical care team(Raymont, et al.).This is not only concerningin that it isunder–recognized,butitputs intoquestion the validity of informed consent.Elements of decision-making capacity include the ability to communicate a choice, the ability to understandand appreciaterelevant informationregarding risks, benefits and alternatives,andthe ability to interpretand manipulateinformation rationally and logically in a coherent manner.If the patient cannotmeet these elements of capacity, then the patient should be evaluated todetermine if restoration of capacity is possible.
Generallyspeaking, medicalproviders are concerned more with a patient’s medical decision-making capacity and they are not typically involved with determining an individual’s financial capacity, driving capacity, testamentary capacity, or ability to consent to a sexual relationship. It is also important to note that a patient can lack capacity in one area but still have capacity in another. For example, a patient may be able to identify a loved one that they trust to serve as their agent, but not have the capacity to consent to a complex medical procedure.A determination of medical decision-making capacity is often best made by the primary physician caring for the patient, who is knowledgeable about the patient’s status and the proposed intervention. Thisdoes not generally require a psychiatric diagnosis or consultation, unless there is concern that a psychiatric diagnosis is specifically resulting in incapacity. In challenging or unclear cases, input from psychiatry or social work can be helpful to the physician to assist them in determining decision-making capacity. For urgent decisions, or if capacity cannot or is unlikely to be restored, a surrogate decision-maker should be utilized.
In the case where a patient lacks medical decision-making capacity and no advanced health care directive exists, state statute determines the order of priority of surrogates who can make health care decisions for incapacitated adults.Even if patients lack medical decision-makingcapacityand consent is sought from someone else,youshouldstillinclude anddiscuss medical decisions with them.It also important to consider mandatory reporting requirements regarding vulnerable adults. Involving other treatment team members, such as social workers, care coordinators, casemanagers, and therapy services is vital to a patient’s successful medical care.
Twocommon mythsarethat,if apatientrefuses medical care ormakes a decisionagainst medical advice, they must lack capacity;ortothe contrary,if a patient agrees with a care plan, theymusthave capacity. Patients have the right to make decisions that providers don’t agree with orthat arebelieved to be poor decisions, so long as the patient demonstrates the elements of decision-making capacity.MIEC encourages providers tomaintainahighlevel of suspicion when a patient’s capacity causesthemto pause. Taking the time toevaluateapatient’sdecision-making capacity not only protects you,butitprotects the patient as well.
