Influences on Decision-making Capacity

00:01 Now, there's also an important thing to recognize that other influences on patients ability to make decisions for themselves.

00:10 So it may be developmental stage.

00:12 So we've generally been talking about adults where we're presuming that they have capacity.

00:16 While a patient that has developmental intellectual disability, they might have only achieved a certain level of intellectual understanding or cognitive function.

00:25 So are they going to actually be able to manipulate the information and give reasons for the decision.

00:31 And again, you have to base it on the decision at hand, it's not a global assessment, it's for the particular medical decision you're asking them to make and then see if they can do that.

00:43 Other chronic influences on capacity could be coming from a particular culture, you know, so are they used to making decisions on their own or is their cultural background where they defer to a family member to make decisions for them, so they're not used to being the one making decisions, again, goes to capability.

01:04 Chronic Illness in and of itself, could also affect capacity, can go both ways, it could mean that they're more experienced of, you know, making medical decisions.

01:13 But it also could mean well, maybe their chronic illnesses is further, you know, debilitating them.

01:19 And they don't have the cognitive wherewithal to process information as well.

01:26 Any prior experience, so either individually that, you know, again, maybe they've made medical decisions in the past, maybe you're asking them to make a medical decision that they've already made in the past, like another surgical procedure that they've been through before, or maybe they've had family members that have gone through similar things.

01:41 The patient that has prior experience may have a better capacity to make decisions.

01:46 They have a better understanding, perhaps, they can reason through it, they've done it before, either for themselves or, or with a family member, that prior experience might aid in their capacity.

01:57 Things that might affect them negatively in terms of an influence on capacity, things like fear.

02:03 Well, maybe they're so overwhelmed by their disease process, they're just so fearful of what might happen with that, that they can't actually do the reasoning ability and process the information to come to a decision.

02:18 There may be patients that have mental health issues, so patients that are in major depression, you know, their judgment may be impaired, maybe they have suicidal ideation, maybe they have, you know, decreased ability to reason through things and you know, a judgment of how to make the decision.

02:35 So you might need to address their mental health issues first, and then determine if they have the capacity to make other medical decisions.

02:45 And then there may also be patients that have cognitive decline over time.

02:49 So patients with developing dementia, maybe in the early phases of dementia, they have the ability to make their own decisions.

02:57 But as the dementia progresses, they may lose that ability that lose that capacity.

03:02 So again, it has to be made on the individual decision you're asking them to make or whether they still retain the capacity to make that decision.

03:12 So those are some more global or chronic issues that might be considered, they're also temporary influences on capacity.

03:19 The first and foremost that you're sure to encounter when you're in the hospital is delirium.

03:24 So a patient comes in with a medical condition, maybe, you know, they're so sick, they have hypoxia, or, you know, just so ill that they've developed a delirium, and you know, they're not able to process information coherently.

03:40 Maybe a patient is coming in intoxicated, either under the influence of alcohol or other substances.

03:46 And that is going to affect their brain function, and ability to, again, understand and process information.

03:53 Maybe it's something that we've done to them, we've prescribed sedatives or opioid analgesics to try to help them with, you know, some symptoms, but those have side effects on affecting their cognitive function.

04:06 So again, you may need to assess whether they still have capacity, even if they receive medication or in some instances, you delay giving them the medication, have them make the decision and then can manage their symptoms.

04:20 There may be other neurologic consequences, people have head injuries or strokes or meningitis, you know, anything that can affect brain function can affect capacity.

04:32 Patient patients that are extremely fatigued.

04:34 As I mentioned, if they have hypoxia, low oxygen to the brain, the brain is not going to work well.

04:39 They have low blood pressure, they're in shock.

04:42 All those things can be temporary influences, once you correct those particular problems, maybe they regained capacity, but certainly in the in the moment, they might affect their ability to make decisions.

04:54 So what do you do as a clinician to figure out when you might need to do a more formal assessment of capacity? So we're still going to rely on those 4 criteria in determining capacity.

05:06 But maybe they are clues that this patient needs a greater in depth assessment.

05:12 So patients, it's been demonstrated that have a mini-mental state exam score of less than or equal to 18 out of 30 really made have the cognitive function, cognitive ability, to either remember the information or be able to process it.

05:27 So, if you have a patient that has dementia, where you get a mini mental state exam score that's less than 18, you might start by questioning whether they have capacity.

05:41 Any patient that has waxing or waning alertness or cognition, they're falling asleep on us, you're talking to them, again, the signs of delirium, you're going to want to do a more formal assessment.

05:53 Maybe it's a patient that makes inconsistent decisions over time.

05:57 As I said, you want some consistency in decisions that are being made.

06:00 If they are changing their mind frequently, or going back and forth, maybe you need to, you know, actually go through the four steps in the assessment to determine whether they have the capacity.

06:14 Maybe they're making decisions, as I said before, that are incongruent with their values or the goals that they've espoused to you of what's important to them.

06:22 If this decision seems out of line with what they've told you is important.

06:26 Maybe you need to, you know, explore further, go more in depth and ask more questions.

06:33 It could be the case that a family member raises concerns like they've seen, you know, an adult child sees that their parent is slowing down or having cognitive decline, they may raise concerns about the patient's ability to make their own decisions.

06:48 We also see in the medical context, that there are patients, you know, if they've lost capacity in the past, maybe they've had delirium with a previous hospitalization.

06:57 It's more likely that they could lose decision-making capacity in the future.

07:01 So that's a red flag that may require you to, you know, do more in depth formal assessment of their capacity.

07:09 And then you also have to be thinking of patients that just are not engaged in the decision-making process.

07:15 They, you know, seem totally unreceptive to hearing the information.

07:21 They, you know, just say whatever you think and, you know, don't want to be bothered, really want to make sure that they are understanding the information and coming to a decision that's working for them.

07:32 Again, we're trying to think about respecting autonomy.

07:35 Part of being autonomous is making your own decisions.

07:38 So if they're limited engagement could be a sign that maybe something's going on with their cognitive function.

07:46 As I said, this is a place where, you know, especially for patients that have dementia, you might need to think about, have they regained it because they lost it in the past? Maybe they had delirium on top of their dementia, is the dementia progressing to the point where they're not going to be able to make the decisions? All of these things may need to be factored in assessing capacity.

08:10 So it's ultimately going to be up to the clinician to make that determination and then figure out what needs to be done for that patient in the future.