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