Threshold Level of Decision-making Capacity

by Mark Hughes, MD, MA

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    00:01 Now that we know the factors that are important for assessing capacity, we then have to make a determination of whether the patient does in fact have capacity.

    00:10 An important side note is to recognize that different decisions will require different levels of capacity.

    00:17 So we'd call this the sliding scale notion of capacity.

    00:21 When a decision becomes more complex or serious, where there's more uncertainty about how the treatment will work, we will then require a higher level of demonstration by the patient, that they have those four elements, that they understood the information, they've reasoned through it, they've applied it to their values and appreciation of their life situation, and can communicate a choice.

    00:45 So, the more complex, more important to make sure that they have capacity.

    00:52 The reason we do this sliding scale appreciation is that we want to avoid two types of errors.

    00:57 So we don't want to prevent a person with capacity from designing their own treatments.

    01:02 And also, we don't want to fail to protect an incapacitated patient from the harmful effects of a bad decision.

    01:09 So we want to make sure the patient is capable of making the decision we're asking them to make.

    01:14 So the other way to look at this is what's known as the threshold level of capacity.

    01:17 So the higher risk, the higher the threshold, we need to demonstrate the patient has capacity.

    01:24 The lower risk decision, the lower the threshold that the patient has to show that they have the capacity for the decision.

    01:30 So a patient that's going into a major surgery where there's potential for adverse effects or complications of the surgery, or there's uncertainty about the outcome, that's higher risk and we really want to make sure that the patient has the capacity to understand all of that information, reason through it, apply it to their life situation and their values and come to a decision.

    01:52 Whereas if you're sending a patient for a complete blood count as a blood draw, you know, a simple procedure of phlebotomy, low risk, you know, low implications, not a lot of uncertainty associated with that decision.

    02:08 You know, just the patient sort of understanding, yes, I'm sending you for a lab, we're going to draw some blood, maybe that's enough and a low threshold for determining that they have the capacity for that decision.

    02:20 Maybe an analogy would help to sort of understand that there's some flexibility in how these decisions are going to be made.

    02:26 So the clinician has to use their judgment about how serious the decision is, how uncertain it might be, how risky it is, and then work with the patient to figure out, do they have the capacity to make this particular decision? Let's use an analogy for this.

    02:44 So think of a jumper, high jumper, you know, that's having to compete in a sport.

    02:51 So when it's a low bar, and they just have to jump over something, you know, it's only 6 inches off the ground, very low threshold for demonstrating that they can accomplish that task.

    03:01 Whereas if you put it at 6 feet in the air, and then they have to jump over it higher threshold, you know, higher demonstration that they have the skill to do so.

    03:10 So same as you know, manipulating the information that we've given them to make a medical decision.

    03:16 Or take a jumper that's, you know, jumping across a puddle, relatively low risk, you know, pretty simple thing to do.

    03:23 Low risk, low threshold for demonstrating that they have the capability of doing that.

    03:29 Whereas you ask him for jump on one building across the street into another building like you've seen in the movies.

    03:34 Well, higher risk, higher threshold, you really want to demonstrate that they can accomplish that.

    03:41 So again, clinical judgment is going to factor into this sort of threshold level of flexible standard sliding scale notion of capacity.

    About the Lecture

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

    Included Quiz Questions

    1. Complexity, seriousness, uncertainty of decision
    2. Complexity, seriousness, certainty of decision
    3. Ambiguity, seriousness, certainty of decision
    4. Ambiguity, complexity, certainty of decision
    5. Ambiguity, seriousness, uncertainty of decision
    1. Low risk = low threshold
    2. Low risk = high threshold
    3. Any risk = high threshold
    4. Any risk = low threshold
    5. Any risk = ethically defined threshold

    Author of lecture Threshold Level of Decision-making Capacity

     Mark Hughes, MD, MA

    Mark Hughes, MD, MA

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