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.