Surgical Palliative Care: Assessing Medical Decision-Making Capacity

Understanding Capacity vs. Competence

• 💡 Capacity is a clinical determination by a healthcare provider, specific to a decision and time.
• ⚖️ Competence is a legal determination by a court, not decision-specific.
• 🤝 For this discussion, the terms will be used interchangeably, focusing on clinical capacity.

Importance and Application of Capacity Assessment

• ✅ Valid informed consent requires a patient with capacity to voluntarily choose treatment after information disclosure.
• ⚖️ If a patient lacks capacity, consent must be obtained from a surrogate decision maker.
• 🧠 Capacity assessments can be implicit (presumed in absence of doubt) or explicit (formal documentation).
• ⚠️ Explicit assessments are crucial for patients with conditions affecting cognition, such as dementia, stroke, or TBI.

The Four Criteria for Assessing Capacity (Applebaum Framework)

• 📝 Understanding: Patient grasps the nature of their condition, treatment, risks, benefits, and alternatives.
• 🤔 Appreciation: Patient acknowledges their medical condition and the consequences of their decisions (insight).
• 🗣️ Communication: Patient can clearly state their chosen treatment option.
• 🧠 Reasoning: Patient can articulate the rationale behind their chosen treatment option.

Clinical Scenarios and Considerations

• ⚠️ Patients with dementia, stroke, psychiatric disorders, cognitive impairment, or TBI are at higher risk for incapacity.
• 🏥 Patients in the hospital with delirium, sedation, or on life-sustaining treatments are also at risk.
• 🤝 Capacity assessments should occur when patients are most participatory and have received and processed relevant information.
• 🩺 Surgeons can and should perform capacity assessments, consulting psychiatry for complex cases or suspected psychiatric illness.
• 🧐 Bias awareness is critical; providers must avoid pre-formed notions about a patient's capacity based on diagnosis or age.
• ⏳ Factors affecting cognition, like delirium, should be corrected before assessment, and capacity can fluctuate.
• ❓ If a patient lacks capacity, a surrogate decision maker is engaged; in emergencies without a surrogate, treatment can proceed under the presumption of reasonable consent.
• 📝 Documentation of capacity assessments and multidisciplinary decisions is essential.

Simulated Patient Scenarios

• 🏥 Scenario 1: A patient with gangrene refuses a life-saving amputation, citing his uncle's negative experience. He demonstrates understanding, appreciation, communication, and reasoning for his choice, thus possessing capacity.
• 🏥 Scenario 2: A similar patient refuses amputation, stating "it's my time" and wanting to go home. Despite understanding the situation to some degree, he fails to demonstrate appreciation for the consequences, indicating a lack of capacity.
• 🩺 In cases of lacking capacity, a second opinion (e.g., psychiatry) and engagement of a surrogate decision maker are recommended.