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Decisional Capacity and Competence

Decisional Capacity and Competence

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Decisional Capacity and Competence

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  1. Decisional Capacity and Competence Walter S. Davis, MD Director of Education Center for Biomedical Ethics University of Virginia

  2. Four Elements of Decisional Capacity (Applebaum and Grisso, 1995) • Understanding • Appreciation • The ability to manipulate information rationally - reasoning • The ability to communicate a choice

  3. Decisional capacity • The set of cognitive, volitional, and affective patient abilities that allows the physician to enter into the consent compact and ask the patient to make specific care decisions

  4. Competence • Best thought of as a legal concept • Determination of competence/incompetence is done by court proceeding, and is usually done in the context of appointing a temporary (“ad litem”) or permanent guardian • Medical “evidence” – either records or real-time testimony – is often presented

  5. Four Functional Abilities in Decisional Capacity Assessment • The ability to express a choice • The ability to understandinformation relevant to treatment decision making • The ability to appreciate the significance of that information for one’s own situation • The ability to reason with relevant information to logically weigh treatment options

  6. Expressing a Choice • Legally a “threshold” issue • Merely expressing a choice or preference does not indicate intact decisional capacity • Clinical interpretation and examples: • Depression • Mental retardation • Communication disorders

  7. Understanding • Most common functional ability used by courts to determine decisional capacity • Psychologically and philosophically complex • Related, in part, to a person’s level of intelligence • Clinical interpretation and examples: • Schizophrenia • Major depression • Medications • Mental retardation

  8. Appreciation • Acknowledgement or appreciation that they suffer from the diagnosed disorder • Acknowledgement of the consequences of the disease and the proposed treatment • Clinical interpretation and examples: • Denial • Lack of insight • depression

  9. Reasoning • Logically weighing options • Clinical interpretation and examples: • Problem focus • Considering options • Considering and imagining consequences • Assessing likelihood of consequences • Evaluating consequences based on one’s own subjective values • Deliberating