Capacity Assessment

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

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