Mental Competency

1. In a patient with a diagnosis that may increase the likelihood of cognitive and/or functional impairment (e.g., dementia, stroke, severe mental illness, head injury):

   • Assess the patient’s level of competence in the context of the decision(s) that the patient needs to make, recognizing that higher-risk decisions require higher cognitive capacity

   • Explain the purpose of the assessment and attempt to gain permission before you begin the assessment

   • Include other professionals when appropriate

2. In an otherwise well patient with subtle changes in function (e.g., family concerns, medication errors, repetitive questions, decline in personal hygiene):

   • Perform an appropriate assessment of cognitive and functional abilities

   • Refer for further assessment when necessary

3. When a patient is making high-stakes care decisions (e.g., surgery/no surgery, resuscitation status) think about the need to assess their decision-making ability.

4. When capacity assessment is required, actively assess the patient’s ability to understand, appreciate, reason, and express a choice.

5. When impaired decision-making ability is identified, attempt to establish severity, reversibility, and duration in order to plan treatment and regular reassessment.

6. When a patient refuses to participate in capacity assessment:

   • Document their refusal

   • Continue to engage in the provision of safe care that is acceptable to the patient

   • Revisit the assessment when indicated

   • Pursue the need for a substitute decision maker when necessary

General Overview

• Mental capacity implies a clinical status established by a healthcare professional

  • Capacity is decision-specific (not global), and may change over time, and in the context of specific domains (medical, cognitive, functional)

• Mental competency refers to a legal status judged by a legal professional

  • Situation-specific (care for self, sign out AMA, stand trial, sign a POA, change a will, financial decisions)

    • May be competent to make care decisions but not financial decisions

• For consent to be considered valid:

  • Must be voluntary (without duress/coercion)

  • Patient must have the mental capacity to consent 

    • Understands nature of proposed options, anticipated effect of options, and consequences of refusing

  • Patient must be properly informed

    • Diagnosis, proposed investigation/treatments, chance of success, alternatives, consequences of refusing

Assessment

• Frame as collaborative effort to ensure patient's wises are honored and safety is protected (not punitive)

• Cognitive screening for cognitive decline (MoCA, MMSE)

• Functional assessment (eg. Katz Index of Independence in Activities of Daily Living)

• Capacity and competence

  • Clinical interviewing

    • Understand information relevant to the decision

      • Cognitive ability to remember the information long enough to make the decision

        • Ask the patient to explain the nature of the condition/treatment/alternatives

    • Appreciate how the information applies to their own situation (ie. insight) 

    • Reason / compare options and infer foreseeable consequences 

      • Weigh up information relevant to the decision or lack of decision

        • Possible outcomes of treatment, alternatives, lack of  treatment

        • Realistic expectations

    • Choice: Express their decision that is reasonable stable/consistent over time in the absence of new information

  • Collateral information

  • Further assessment

    • Integrated multidisciplinary approach when appropriate 

      • Psychiatry

      • Occupational therapy (on-road assessment, kitchen-cooking assessment)/physical therapy

      • Social work

      • Neuropsychology

    • Consider reversible causes

      • Medication review (anticholinergics, benzodiazepines, opioids, polypharmacy)

      • Laboratory testing: CBC, Electrolytes (Sodium, Calcium, BUN/creatinine, Glucose), ALT , TSH, vitamin B12, folate; consider syphilis, HIV, urinalysis

      • Depression screening (Geriatric Depression Scale) 

      • Delirium assessment (Confusion Assessment Method) 

      • Brain imaging (MRI or CT head to rule out structural causes)

• Advance Care directive (Living Will) prior to onset of impairment or early in progressive conditions

• Substitute decision maker

  • If not assigned, by hierarchy:

    • Guardian appointed by the court

    • Power of Attorney for personal care

    • Representative appointed by Consent and Capacity Board

    • Spouse, common-law spouse or partner

    • Child (if >16yo) or parent (custodial)

    • Parent with right of access only (non-custodial parents)

    • Brother or sister

    • Any other relative

    • Office of the Public Guardian and Trustee