OT Assessment for Capacity

Legal Capacity means a person is able to:

• Understand the nature and effect of their decisions
• Freely and voluntarily make decisions
• Communicate the decision in some way

Know What Incapacity Is Not

• Ignorance
• Low Intellectual Function
• Annoying behaviour
• Eccentricity
• Unconventional Views or Choices
• Communication Failure

Unspoken Principle

• As we speak, all over the world, many thousands of ‘normal’ adults are doing really stupid, dangerous and strange things
• They are free to engage in injurious health behaviours, mismanage their finances and put themselves in situations of physical risk or squalor
• The line between capacity and lack of capacity is sometimes very thin

Capacity is not all or nothing, it is:

• Decision specific (may be able to consent to X-ray but not quadruple bypass)
• Domain specific (may be able to manage finances but not health care)
• Time specific (person may be well enough to nominate Enduring Power Of Attorney on Tuesday when wasn’t on Monday)

Most common questions asked are:

• Can this person give/revoke EPOA ?
• Can this person make their own lifestyle decisions ?
• Can this person manage their own finances ?
• Can this person consent to treatment ?
• Can this person stand trial ?

How do we seek out evidence relating to capacity ?

• Clinical history gathering/taking/observation and interviewing represent the most ecologically valid and fair method of arriving at comments on capacity
• Collateral history for comparison is imperative
• For ethical and validity reasons, the person must know why we are examining and questioning them

How do you do this ?
For EPOA demonstrate they understand :

• The nominated attorney can do what the principal can
• They understand when it begins
• They understand they can specify or limit the power
• They understand they can revoke it at any time if capable
• They understand it will continue while they suffer incapacity
• If they cannot revoke it, they cannot control the use of the power

Health Care Capacity

• Need to receive, comprehend, retain, and recall relevant information
• Integrate information received and relate it to one’s situation
• Evaluate risks and benefits in terms of personal values
• Select an option and give sensible reasons for choosing that option
• Communicate one’s choice
• Persevere with that choice at least until option is acted on

Lifestyle Decision Capacity
Person needs to:

• Understand the risks in their environment with respect to their abilities
• Understand the need for, and accept, help where risks are present

Financial Capacity

• Understand income and expenses at basic level
• Exhibit the ability to work with finances by making calculations, handling money
• Exhibit some ability to plan and regulate spending
• The levels at which these skills are needed varies greatly with complexity of finances

Recording

• Think ‘evidence’ rather than just opinion or MMSE score – document capacity related events and behaviour
• Document actual questions asked and answers given in forming capacity opinion    Document evidence from multiple sources
• Document when, where and how long for Ax
• Consider and include prognostic information where relevant

Consider Reversibility, Improvements

• Be especially vigilant for delirium
• Where a condition may possibly improve with time report this
• Where it is predicted to worsen likewise report this
• Where a review is appropriate, recommend a timeframe

Basic Guidelines

Chart review
Initial Assessment with patient
Collateral histories:
-family
-GP
-care providers
-neighbours
Cognitive Assessment
-MMSE, MEAMS, CAM, RBMT, RUDAS, MSQ
Functional Assessment
-AMPS, PRPP
-MBI, kitchen, shopping, money
Questioning
-safety and judgement
-understanding decisions
Much liaison with MDT