Introduction to Decision-making Capacity

by Mark Hughes, MD, MA

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    00:01 In the past lecture on informed consent, we talked about the patient's ability to make their own decisions.

    00:08 There are going to be situations where we encounter patients where it's not really clear whether or not they have the capacity to make decisions.

    00:15 So this lecture is going to go through a process of thinking about decision making capacity.

    00:22 If you recall from the lectures that we talked about with ethical theory, we talked about respect for autonomy, and there are certain conditions to being an autonomous agent, be able to be a person that can make decisions.

    00:35 The first element or first condition is that you have intentionality.

    00:39 So if you're going to perform an action, that you have the intent of performing that action, and that usually means that it's consistent or corresponds with the individuals conception or plan.

    00:51 So they intend the action they follow through and having the action.

    00:55 Another condition for autonomy is understanding.

    00:58 So when we're thinking about decision making, they have to have a knowledge base by which to make their decisions.

    01:04 It doesn't mean they have to know everything.

    01:06 It's not omniscience that we're after, but at least, especially for medical decisions, the idea that they have a understanding of the nature of the action that they are intended to perform, as well as the foreseeable consequences, or outcomes to be expected from that decision.

    01:25 And then lastly, there has to be voluntariness.

    01:27 We mentioned this in the informed consent lecture.

    01:29 But this is another place where we really make sure that the patient is free from any external control in making their own decisions or performing their own actions.

    01:38 So sort of those are the conditions for autonomy.

    01:43 So let's talk a little bit more about voluntariness.

    01:46 So that means not being under the control, or undue influence of another person.

    01:52 And there can be various ways that a person could be influenced.

    01:55 And here are some of the categories of influences on a person.

    02:00 So maybe there's persuasion.

    02:02 So you're trying to convince a person to make a certain decision or perform a certain action.

    02:07 So you're using reasoning trying to reason with them have a discussion with them trying to persuade them of a certain course of action.

    02:16 And that generally is going to be considered permissible when we're thinking about informed consent in the medical setting.

    02:23 Where it starts to become concerning in terms of categories of influence would be something like manipulation.

    02:29 So you're altering the information or how you're relaying it to the patient in order to achieve a certain goal.

    02:34 You're trying to convince them or unduly persuade them about reaching a decision.

    02:40 So that kind of manipulation may not be morally permissible.

    02:44 And lastly, for sure, coercion is morally impermissible.

    02:49 Any kind of threat of harm or undue influence of the individual, you have to avoid, we really want the person to make decisions voluntarily of their own freewill that's being autonomous.

    03:04 So the other precondition for informed consent besides voluntariness is decision making capacity.

    03:10 So it's really one of the core features, the need to assess as you're going through the informed consent process.

    03:18 And what does it actually mean, it means the patient is able to understand the information that's given to them, manipulate that information using their reasoning ability, in order to make and communicate a decision to the clinician.

    03:31 And it's important to recognize that all adult patients are presumed to have capacity until proven otherwise.

    03:38 So prima facie, you know, on first blush, we are saying, patient is going to have capacity, It's only when there might be red flags that we'll talk about in future lecture, where we might say, well, maybe we need to assess, does this person have the ability to make their own decisions? There going to be four main aspects that are required for decision-making capacity.

    04:02 The first that we focused on in the informed consent lecture is this idea of understanding.

    04:06 So being able to comprehend the medical information that's being given to them.

    04:12 Second, an appreciation of that information, really how it's significant to them in their own life situation.

    04:20 So perhaps they're given a diagnosis, they're given a prognosis.

    04:24 They're told about treatment options, they have to put that in the context of their own life and appreciate the impact of the disease and the treatment on their life situation.

    04:38 Next, another aspect of decision-making capacity is their reasoning ability.

    04:43 So if they're given, you know, a broad range of information.

    04:46 If they're given alternatives, you know, the physician might recommend one line of treatment but are given alternatives.

    04:54 They then have to decide, how is this going to work for me? Reason through the options and then make a decision based on their values and the consequences of the decision that they can foresee.

    05:08 And ultimately, they have to make a choice.

    05:11 They have to communicate back.

    05:12 Yes, I've heard the information and I've understood the information.

    05:15 I've reasoned through it, sort of appreciate it in sort of who I am as a person.

    05:20 And now I'm making a decision.

    05:22 "This is what I want to do about the treatment."

    About the Lecture

    The lecture Introduction to Decision-making Capacity by Mark Hughes, MD, MA is from the course Informed Consent and Capacity.

    Included Quiz Questions

    1. Aptitude
    2. Intentionality
    3. Understanding
    4. Comprehension
    5. Voluntariness
    1. Yes, it is sometimes appropriate as a way of explaining one's understanding and rationale.
    2. Yes, it is always appropriate.
    3. No, it is never appropriate.
    4. Yes, it is sometimes appropriate in cases when a patient is asking too many questions.
    5. It is only appropriate for physicians who are board-certified.
    1. Ambulating into the examination room
    2. Understanding
    3. Appreciation of the information
    4. Reasoning
    5. Communicating a choice

    Author of lecture Introduction to Decision-making Capacity

     Mark Hughes, MD, MA

    Mark Hughes, MD, MA

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