Is Mom Competent to Make Decisions About Her Medical & Personal Care – or Her Finances?

As more and more people are living longer these days, families and physicians are increasingly struggling with this question. 

The above question is, however, incorrectly phrased. 

First, there is a difference between competence and capacity. 

Competency is the degree of mental soundness necessary to make decisions about a specific issue or to carry out a specific act. It is a judicial finding made by the court.  

Capacity is a person’s ability to make an informed decision, but also:

• Is specific to the question at hand. For example, deciding who should make decisions about one’s medical care is usually a much more simple decision, compared to making a decision about open heart surgery.
  
  
• Changes over time, sometimes rapidly, like when a person is acutely ill.
  
  
• Has no specific, simple, quick test. 

Physicians and families often fail to recognize incapacity in patients. Approximately 25 percent of adult inpatients lack capacity due to illness-related mental confusion and other reasons. 

In outpatients, capacity is often questioned in patients with dementia and mental health issues, although the presence of those conditions does not render a person incapable of making decisions. 

Second, the question of a person’s competency should include the domain in which decisional ability is questioned. For example, “Does Mom have decisional ability to refuse surgery or handle her finances?” 

Financial and personal care issues are typically not addressed by health professionals, although seeking their assistance is often a first step, followed by a referral to social or legal services.

So what about a frail, sick, older person who is just a little bit forgetful? Their families are frequently asked to make burdensome decisions, such as whether to start dialysis or life support. 

It is not unusual for them to turn to Mom or Dad asking, “What do you want?” Even if Mom or Dad gives an answer, how do we know that the answer is a result of good understanding, truly representing their best interest? 

I have witnessed families asking, “Mom, if your heart stops, do you want the doctors to try resuscitation?” 

An answer like “I guess so” should not be considered an informed medical decision. In these situations, a capacity evaluation by a physician might be called for. 

What constitutes a capacity evaluation?

A capacity evaluation tests a patient in three areas:
 

1. Comprehension refers to one’s understanding of his/her medical condition. This includes:

• Risks and benefits of treatment.
  
  
• Reasonable alternatives.
  
  
• The way the situation relates to his/her condition.
  
  
• The consequences of his/her decisions. 

The patient also should demonstrate a rational manipulation of information, applying a coherent and logical thought process to analyze possible courses of action. 

Communication is a key component of capacity evaluations. Barriers to good communication (hearing loss, language issues, etc.) can lead to the perception that the patient lacks capacity.

2. Free choice means that the patient’s decision to accept or reject a proposed treatment is voluntary. The physician should determine whether choices have been made because of unrealistic fears or expectations about treatment, or even the desire to please family.
 

3. Reliability refers to the ability to provide a consistent choice over time. A patient who vacillates or is inconsistent does not have capacity to make decisions. 

If you or a loved one has questions regarding competency issues, the first step is to speak with your attending physician. 

If appropriate, your physician may refer you to palliative care, which is a form of specialized medical care that focuses on improving the quality of life for patients with a serious illness and their families. 

To learn more about palliative care services and programs available at Hawaii Pacific Health, click here.

Published on: April 28, 2016