1. UMMS CRIT Module I: Understanding Decision-Making Capacity Gary Blanchard, MD Division of Geriatric Medicine UMMS

2. UMMS CRIT 2012 Module I: Understanding Decision-Making Capacity Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Upon completion of this lecture, the participants will be able to: –Explain the principles of decision-making capacity. –Recognize that no disease – including dementia – automatically negates decision-making capacity. –Identify common misconceptions about capacity. –Apply the principles of capacity assessment in their daily clinical encounters. Objectives

3. UMMS CRIT 2012 Module I: Understanding Decision-Making Capacity Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Retrieved April 20, 2010 from http://artfiles.art.com/5/p/LRG/22/2207 /5VAAD00Z/norman-rockwell-doctor- and-the-doll.jpg Paternalism

4. UMMS CRIT 2012 Module I: Understanding Decision-Making Capacity Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Patients have the right to make what we consider to be bad decisions, including refusing treatment that we think is in their best interest. Patient Autonomy

5. UMMS CRIT 2012 Module I: Understanding Decision-Making Capacity Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation We as physicians must feel that a patient has the capacity to make that specific decision … But theres a catch …

6. UMMS CRIT 2012 Module I: Understanding Decision-Making Capacity Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Retrieved April 16, 2010 from http://www.homeownershiprevo lution.com/images/Here%20Co mes%20The%20Judge.jpg http://www.homeownershiprevo lution.com/images/Here%20Co mes%20The%20Judge.jpg Retrieved April 16, 2010 from http://ts1.mm.bing.net/images/thumbnail.aspx?q=162732 5924800&id=9a0c12d9f878bf67bd5adf96fec7bb15&url =http%3a%2f%2fwww.facebook.com%2fprofile%2fpic.p hp%3foid%3dAAAAAQAQOYY- wNCuQPKRrJ0oI1M69wAAAA8_c3DwT6DY- 1jOtMaUKFMI Capacity vs. Competence

7. UMMS CRIT 2012 Module I: Understanding Decision-Making Capacity Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Retrieved April 16, 2010 from http://online.wsj.com/media/scales _art_160_20080808131250.jpg Decision-Making Capacity Ideally, balance the respect for a patients autonomy with protecting a vulnerable patient from the consequences of a bad decision. No clear guidelines – clinical, legal, and ethical considerations

8. UMMS CRIT 2012 Module I: Understanding Decision-Making Capacity Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation –Expresses appreciation of the situation –Understands consequences of the decision –Manipulates information –Reasons coherently –Able to paraphrase Standard of Informed Consent

9. UMMS CRIT 2012 Module I: Understanding Decision-Making Capacity Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation In general, we only think of the notion of capacity when someone disagrees with our treatment plan. Literature suggest that 40-50% of medical patients admitted to the hospital lack decision- making capacity(!). We Dont Think Of It Enough …

10. UMMS CRIT 2012 Module I: Understanding Decision-Making Capacity Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Vast majority of people possess capacity Decision-specific (medical, financial, housing) – not all of nothing … and may fluctuate! Standard proportional to risk (sliding scale) –High Risk – High Standard –Low Risk – Low Standard Pearls/Guiding Principles

11. UMMS CRIT 2012 Module I: Understanding Decision-Making Capacity Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation No disease alone – like dementia – automatically negates decision-making capacity. No magic MMSE number (also important to remember shortcomings of MMSE) A patient may continually forget the facts of their condition – but can they express their values when you repeat the scenario to them? Who Lacks Capacity?

12. UMMS CRIT 2012 Module I: Understanding Decision-Making Capacity Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation History (medical, psychiatric, social) Cognitive testing Functional assessment Assess a patients values and goals of care Evaluating Capacity

13. UMMS CRIT 2012 Module I: Understanding Decision-Making Capacity Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation 1.Communicate a choice 2.Understand the relevant information 3.Appreciate the situation and its consequences 4.Reason about treatment options Core Principles Unfortunately, no one useful, validated tool for assessing capacity currently exists. Appelbaum, P.S. (2007). Assessment of patients competence to consent to treatment. New England Journal of Medicine, 357 (18). 1834-1840.

14. UMMS CRIT 2012 Module I: Understanding Decision-Making Capacity Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Clearly indicate preferred treatment option –Have you decided whether to follow your doctors recommendation for treatment? –Can you tell me what that decision is? –What is making it hard you for to decide? Communicate a Choice

15. UMMS CRIT 2012 Module I: Understanding Decision-Making Capacity Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Grasp the fundamental meaning of information communicated by physician Please tell me in your own words what your doctor told you about … the problem with your health now the recommended treatment the possible benefits and risks of the treatment and any alternatives. Understand the Relevant Information

16. UMMS CRIT 2012 Module I: Understanding Decision-Making Capacity Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Acknowledge medical condition and likely consequences of treatment options –What do you believe is wrong with your health now? –What do you believe will happen if you are not treated? –Why do you think your doctor has recommended this treatment? Appreciate the Situation and Its Consequences

17. UMMS CRIT 2012 Module I: Understanding Decision-Making Capacity Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Engage in a rational process of manipulating the relevant information –How did you decide to accept or reject the recommended treatment? –What makes [chosen option] better than [alternative option]? Reason about Treatment Options

18. UMMS CRIT 2012 Module I: Understanding Decision-Making Capacity Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Surrogate Decision-Making Reflects self-determination and Western notion of personhood, especially pronounced in the United States (bioethical hierarchy): –Patient (who possesses decision-making capacity) –Patients Known Wishes –Substituted Judgments –Patients Best Interests

19. UMMS CRIT 2012 Module I: Understanding Decision-Making Capacity Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Massachusetts Health Care Proxy Law Legal Guardian Section 12 Massachusetts rules

20. UMMS CRIT 2012 Module I: Understanding Decision-Making Capacity Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation THE SIMPSONS. Dr. Nick Riviera on THE SIMPSONS on FOX. 2002T HE SIMPSONS and TTCFFC ALL RIGHTS RESERVED 2002F OX BROADCA STING CR:FOX Take Home As a physician, there is no greater responsibility you possess than assessing your patients decision- making capacity.

21. UMMS CRIT 2012 Module I: Understanding Decision-Making Capacity Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Lessons Learned