Decisional Capacity and Refusal of Treatment 9-29-14 Flashcards
What is competence?
A legal term
All adult patients are considered competent until a court proves otherwise
A physician can make a determination of capacity without a psychiatrist
Are minors competent?
Generally not, with some exceptions.
Only parents or legal guardians can make decisions.
Consent is implied in emergencies.
Minors generally held incompetent legally except for the following:
“mature minor”
Over age of discretion (15)
Minor sought care independently and demonstrates capacity
Care is medically necessary for the patient’s own benefit
Good reason for lack of parental consent
Emancipated minor
Living independently of parents
Certain medical conditions
Varies by state but usually involves addiction, STI’s, and/or contraception/abortion
What is an emancipated minor?
A minor that is free to make all health care decisions
Qualifications:
1. Married, self-supporting and living independently
2. In the military
Generally, no longer depend on parents for support
What are some limitations on parental right of refusal for minors?
- Cannot refuse treatment due to religious belief
2. Cannot refuse treatment if child is severely brain-damaged/developmentally delayed.
Can patients with mental illness or developmental delays refuse care if they are adults?
Yes
What is decisional capacity?
DECISIONAL CAPACITY
Possessing the ability to make and express decisions
What is competence?
COMPETENCE
A legal term usually meaning that a person possesses and can legally exercise decisional capacity
Limited by factors such as age, mental status and medical condition
What are the 5 components of decisional capacity?
UNDERSTANDING
Knowledge and comprehension of facts
APPRECIATION
Knowing the nature and significance of the decision
REASONING
Ability to manipulate information rationally
Ability to weigh risks, benefits, consequences and possible outcomes
EXPRESSION OF CHOICE
Ability to convey decision to others
VALUES AND EMOTION
A concept of what is good for the person
How is decisional capacity assessed?
Decisional capacity is usually assumed unless the patient gives a reason to doubt it
Decisional capacity assessment must be case-specific, ie. tied to a particular decision for a specific patient at a specific place and time
Decisional capacity is considered relative, ie. more ability needed to consent to higher risk/lower benefit decisions
Some conditions affecting decisional capacity are modifiable, while others are not
Assessment must be tied to the 5 components of decisional capacity and documented as such
Assessment should be approached with a balance between respect for autonomy and protection from harm (Autonomy vs. non-maleficence)
What is decisional incapacity?
Decisional incapacity is a common, but often unrecognized condition, especially in acute-care settings
Is assessment of decisional capacity legal or clinical?
Clinical, not legal
In a practical sense, how is assessment of decisional capacity done?
Standard tests are available to aid in assessing decisional capacity, but all have limitations
Mini-Mental State Exam (MMSE)
MacArthur Competence Assessment Tool for Treatment (MacCAT-T Test)
Systematic question sets
Difficult determinations may require psychiatric or ethics committee consults, or legal intervention to declare the patient incompetent, if time allows
What does irrational refusal require?
Irrational refusal requires further investigation and, sometimes, treatment in spite of patient’s refusal
