Compassion and Support

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Medical Orders for Life-Sustaining Treatment - Professionals

Capacity Determination

Capacity is the ability to take in information, understand its meaning and make an informed decision using the information. Intact capacity permits functional independence. Capacity requires a cluster of mental skills people use in everyday life and includes memory, logic, the ability to calculate and “flexibility” to turn attention from one task to another.

Executive functions are the cognitive processes that orchestrate relatively simple ideas,  movements or actions into goal-directed behaviors.  Without executive functions, behaviors important for independent living can be expected to break down into their component parts.

Please note:  competence and incompetence are legal terms.  These terms imply that a court has taken specific action.

Capacity is task-specific.  Clinicians determine a patient's capacity to make decisions regarding medical care and treatment, managing money, writing a will, continuing to drive, possessing firearms etc.  The overarching principle in capacity determination is the assessment of the patient's ability to understand the consequences of a decision.

Capacity requirements vary by task.  The capacity to choose a trusted individual as an appropriate Health Care Agent differs from the capacity to agree to a medical procedure or treatment.  A patient may retain the capacity to choose a health care agent at the time they cannot make medical decisions.

Several types of medical decisions are made by a health care agency or surrogate decision-maker, if the patient loses the capacity to make these medical decisions

  • Medical decisions about life-sustaining treatment, including cardiopulmonary resuscitation, intubation and mechanical ventilation, dialysis and feeding tubes.
  • Medical decisions about ordinary treatment; for example antibiotics
  • Medical decisions about palliative care; for example pain and symptom management

Capacity determination regarding a patient's decisions regarding the medical care and treatment is often difficult to establish.  There is no standard "tool."  Capacity assessment is a complex process and is not simply determined by the Mini-Mental Status Exam (MMSE).  Capacity assessments should involve a detailed history from the patient, collateral history from family, focused physical examination including cognitive, function and mood screens and appropriate testing to exclude reversible conditions.

Capacity determination involves assessment of three key patient abilities

  • Ability to understand relevant information about his or her condition and the probably outcomes of the disease and of various potential interventions and its meaning in terms of the disease process; proposed therapy and alternative therapies. Advantages, adverse effects and complications of each therapy; and possible course of the disease without intervention.
  • Ability to make an informed decision using the information, based on his or her beliefs and values and understands the consequences of the decision.
  • Ability to communicate a decision.

A physician evaluates a patient and determines capacity to make medical decisions.  Under FHCDA, in a hospital or nursing home, a health or social service practitioner can provide a concurring determination when a surrogate is making a decision.

Learn more about "Capacity Determination" under Family Health Care Decisions Act (FHCDA)

Click on the links below to view the archived PowerPoint presentations on Capacity Determination

For more information on MOLST, VIEW HERE 

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