A VIEW FROM THE OFFICE

HOW DO YOU KNOW IF SOMEONE IS COMPETENT 

TO MAKE A DECISION FOR HEALTH CARE

    The determination of whether someone is competent to make their own decisions is very difficult. Over the last 20 years numerous experts have taken their best shots at designing algorithms or questionnaires to help primary care physicians to make this determination with relatively little success. In this article I am sharing the result of a recent study of the different instruments that have been developed for this.(1) The instrument that has been the best tested and validated is called the "Aid to Capacity Evaluation." A copy of this form is available as a free PDF file online and includes instructions for use.
     My reason for including this information in a consumer blog is because it is often too late to be practical if the family waits for a physician to do the evaluation. These kinds of decisions are best anticipated. Most relatives and friends of someone whose health is deteriorating to the point of being unable to make a quality decision for themselves are aware that in some areas of life the patient should not be left on his/her own. Reviewing this form allows family members to walk through the steps to assess the different areas of capacity/competence. Once family members get to the point of thinking this may be helpful, it is time to formally prepare a document expressing the patient's wishes for end-of-life care or other critical health decisions. Ideally, this can be done before the patient becomes incompetent across the board.
     The legal background for this issue is that all adult patients (over the age of 18) are presumed by law to be competent. Even if a patient has severe chronic disease, even chronic mental illness like schizophrenia, the initial legal presumption is that they are capable of making their own decisions. In general, psychiatric patients cannot be compelled to take their medications. Psychiatric patients are presumed capable of determining whether they want a surgical procedure or not, even if a "reasonable" person of the same age would reach a different conclusion. They are not required to make the "correct" decision (whatever that is). The decision just needs to reflect a minimal understanding of the problem or issue, a clear and consistent preference (whether logical or not), and not be obviously impaired by other illness, particularly depression or delusions. A person with a chronic mental illness such as schizophrenia or dementia can be quite capable of expressing a meaningful decision about a surgical treatment or diagnostic test even when they care clearly incompetent to manage their own finances, hygiene, or usual activities of daily living. So to say a person has dementia, by itself, has no specific implications for their capacity to make medical decisions.
     An individual can be deprived of their right to make their own decisions only by an authorized police official (e.g., for a 5150 Psychiatric hold for 72 hours to perform a formal evaluation of competence and safety) or judicial determination (a competency or custodianship hearing). The police action is only a temporary one. The judicial action obviously requires significant time to go through the steps of finding an advocate, reviewing relevant documents and witnesses, and scheduling a formal hearing on the court docket. As a practical matter, the legal system is simply not capable of responding quickly enough to assist in making decisions about an individual's competency to be helpful when it is needed. That is why it is so important that family members or anyone who takes part in the care or support of a patient proactively address these issues well in advance of acute illness or the need for something like nursing home placement when the patient says s/he does not want to go.
     I believe that the form below is very simple and clear to follow. A lay person can walk through the appropriate evaluation process for someone s/he is concerned about. It is so much better to have this process addressed early in the course of chronic illness, even by a lay person, than it is to wait until the situation is urgent and then try to have a doctor do it. Legally a doctor cannot make the determination that someone is not competent to make a decision. If an advance directive is not in place, then the legal process will have to be invoked.

THE AID TO CAPACITY EVALUATION

[Record observations that support your score in each domain, including exact responses of the patient.  
Indicate your score for each domain with a circle.]


1. Able to understand medical problem 
      (Sample questions: What problem are you having now? What problem is                
        bothering you most? Why are you in the hospital? Do you have (name
        problem)?)            

             YES                   NO                UNSURE
                                                                                            
        Observations:  ______________________________________________  
   
__________________________________________________________

2.  Able to understand proposed treatment 
     (Sample questions:  What is the treatment for [your problem]?
       What else can we do to help you? Can you have [proposed treatment]?

             YES                   NO                UNSURE
         
       Observations: ______________________________________________
        _________________________________________________________

3.  Able to understand alternative to proposed treatment (if any)
     (Sample questions: Are there any other [treatments]? What other
       options do you have? Can you have [alternative treatment]?

             YES                   NO                UNSURE                 UNDISCLOSED


       Observations: ______________________________________________
                                                                                                                                                   
      __________________________________________________________

4. Able to understand option of refusing proposed treatment 
      (including withholding or withdrawing proposed treatment)
       (Sample questions: Can you refuse [proposed treatment]? Can we stop
        [proposed treatment]?

             YES                   NO                UNSURE


        Observations:  _____________________________________________
        _________________________________________________________

5. Able to appreciate reasonably foreseeable consequences of
     accepting proposed treatment
(Sample questions: What could happen to you if you have [proposed
 treatment]? Can [proposed treatment] cause problems/side effects?
 Can [proposed treatment] help you live longer? )

             YES                   NO                UNSURE


       Observations:  _____________________________________________
        _________________________________________________________

6.   Able to appreciate reasonable foreseeable consequences of 
        refusing proposed treatment (including withholding or 
        withdrawing proposed treatment) 
        (Sample questions: What could happen to you if you don't have [proposed
        treatment]? Could you get sicker/die if you don't have [proposed treatment]?
        What could happen if you have [alternative treatment]? (If alternatives are available)

             YES                   NO                UNSURE


       Observations:  _____________________________________________
        _________________________________________________________

(Note: for questions 7a and 7b, a “yes” answer means the person’s decision is affected by depression.)


7a. The person's decision is affected by depression
       (Sample questions: Can you help me understand why you've decided to
        accept/refuse treatment? Do you feel that you're being punished?  Do
        you think you're a bad person? Do you have any hope for the future?
       Do you deserve to be treated? )

             YES                   NO                UNSURE


      Observations:  _____________________________________________
        _________________________________________________________

7b. The person's decision is affected by psychosis
       (Sample questions: Can you help me understand why you've decided to
        accept/refuse treatment? Do you think anyone is trying to hurt/harm
        you? Do you trust your doctor/nurse? )
             YES                   NO                UNSURE


       Observations:  _____________________________________________
        _________________________________________________________


Overall Impression 


Definitely capable     Probably capable     Probably incapable     Definitely incapable 


Comments:
(for example: need for psychiatric assessment, further disclosure and discussion with patient
or consultation with family)

The initial ACE assessment is the first step in the capacity assessment process.  If the ACE is definitely or probably incapable, considerable treatable or reversible causes of incapacity.  Repeat the capacity assessment once these factors have been addressed.  If the ACE result is probably incapable or probably
capable, then take further steps to clarify the situation.  For example, if you are unsure about the person’s ability to understand the proposed treatment, then a further interview which specifically focuses on this area would be helpful.  Similarly, consultation with family, cultural and religious figure and/or psychiatrist,
may clarify some areas of uncertainty.

Never base a finding of incapacity solely on your interpretation of domain 7a and 7b.  Even if you are sure that the decision is based on a delusion or depression, we suggest that you always get an independent
assessment.

Time taken to administer ACE:   ______ minutes
Date:  ______________
Assessor: _______________________________

COMMENT: You will notice that the form records its conclusion in a "fuzzy" way--"probably" vs. "definitely" capable or incapable. This is as good as it gets. If you need to seek more clarity, you seek more input (additional evaluations using the same instrument from other people who know the patient well or other professionals with special expertise in these kinds of assessments. Just remember that no expert is qualified, on his own, to make a determination that a patient is not competent to make a medical decision. In the end, only a court can do this if the patient has not previously appointed a "health care proxy" to make these decisions when s/he should become no longer able.


References:


1. Sessums LL, Zembrzuska H, Jacksoni JL. Does this patient have medical decision-making capacity? JAMA 2011; Jul 27; 306(4): 420-7.

Reliable Quick Answers to Medical Questions on the Web

A VIEW FROM THE OFFICE

RELIABLE QUICK ANSWERS TO MEDICAL QUESTIONS ON THE WEB:

WELCOME TO HEALTHTAP!

     Two weeks ago I read in the Sunday New York Times an article about a web-based consumer information service called "HealthTap." It invites both consumers and physicians to join. Consumers ask the questions. Volunteer physicians provide the answer. HealthTap started its Web site last May. It has signed up more than 9,000 physicians and is adding 100 a day. The site does not carry advertising. "Users can follow particular doctors and topics of interest; new answers related to these are displayed in an “activity feed” shown when users log on to the site. The site offers a peer-based reputation system of its own devising. Next to each answer, users see the number of doctors who agree; with a click, they can see who the approving doctors are, as well as something that HealthTap calls a “reputation level,” which is built by accumulating HealthTap awards, “Agrees” from fellow physicians and other measurable activities at the site."  

Here is a screenshot from the patient side of the website:

Here is a screenshot from my physician side of HealthTap.

      Probably the strongest feature about this site for consumers is the ability to "follow" the opinions of certain physicians who give precise, clear, practical answer. [Some of the answers are indeed too brief to be helpful.] You will be notified of new responses for the physicians that you follow. [You are certainly welcome to follow me.] 
     For the physicians it is an excellent opportunity to reach out to patients outside of the office and to do good for the community (in fact, a very big community--the whole internet!). It can also sharpen physician skills in communication. Trying to be helpful, succinct, and clear in only 400 characters [the limit for each answer] is a good mind-sharpening challenge. I find it an excellent way to both learn something and be useful in the few minutes between patients in the office. It is always informative to see the kinds of things that patients are concerned about but may not bring to the office. Some of the questions are distinctly challenging and send me to do online research so that we can both be educated at the same time. In my opinion, any way that a doctor can make more contact with the community is a good thing. 
     HealthTap offers a very sociable and time-efficient way of getting in touch with a treasure trove of physicians. Try it!


A NOTE TO MY FRIENDS IN PLUMAS COUNTY:  I will be returning to do a Saturday morning clinic on March 3rd at the Portola Clinic. The plan is for me to come back for a clinic session on the first Saturday of each month. I look forward to seeing you there.

Dr. Colin Kopes-Kerr, MD

ARE THE TESTS YOU ARE GETTING WORTHWHILE?

A VIEW FROM THE OFFICE

ARE THE TESTS YOU ARE GETTING WORTHWHILE?

     An important new article in the Annals of Internal Medicine urges physicians (and ultimately their patients) to limit a lot of common testing based on the value to the patient (Will the test actually improve the patient's outcome?) and the cost to the system, which in the end we all pay.

     They have selected 34 tests as appropriate targets for reduced use. Here I will comment on the tests that I have seen most often used in Plumas County with little or no benefit to either the physician or the patient.

     

1. Bone Mineral Density Testing: The national guideline from the United States Preventive Services Task Force does not call for routine DEXA scanning of average risk women until age 65. As I have explained in a recent post here, new evidence shows that for average risk women with normal DEXA scans at age 65, they do not need another one for 15 years! I have seen many women who have been coming in for one every year or every other year.

    Even for women at high-risk or who have abnormal scans at baseline, there is little evidence to suggest any benefit to repeating the scans in less than 5 years. 

2. Lipid panel testing. Many people come in for a lipid panel every year or sometimes even more often. The recommendation for asymptomatic health persons is to have this done every 5 years starting at age 30. If you're not on any treatment, there is no need to repeat more often than this. Even if you are on treatment, a British Study (The British Heart Study) has shown that once you select the treatment and just continue the medication, as long as there are no side  effects, you don't need to recheck the lipid panel or adjust the dose (ever). You can still get exactly the same 33% reduction of all-cause mortality and cardiac events that you do when you get all the extra tests and medication adjustments. Why go through all that extra trouble and expense?

3. Pre-operative testing: Many surgeons, almost all, in fact, want patients to get an elaborate set of blood tests, urinalysis, chest x-rays, and ECGs before they have any kind of elective surgery. I recently had occasion to undergo an upper GI endoscopy twice. When I had it done here, the Portola hospital did not require any specific testing, but when I need to have the endoscopy repeated at Saint Mary's they routinely threw in a requirement for blood counts, chemistry panel, coagulation tests, urinalysis, chest x-ray, and ECG. This was more than a little irksome since they did not inform me of this in advance, and because I knew it was ultimately pointless. All tests were in fact normal, and I lost both time and money. This report strongly advises against all forms of routine preoperative testing for average risk adults before any general elective surgery.

      COMMENT: Of course, this is usually not a decision you make yourself. Your surgeon makes it. But you can, and should, ask why. And don't be afraid to bring them a copy of this article and the reference supplied below to encourage them to think twice about ordering unnecessary tests.

4. Colon cancer screening: This group also takes a strong stand against any routine colon cancer screening after the age of 75. You can get it, if you really want it, but there is no evidence of systematic benefit at this age.

5. Cervical cancer screening: There is no reason that a healthy 65 year old woman needs additional Pap smears as long as she has had regular screening up to age 65 (every 3 years) and they have all been negative over the last 10 years.

6. Prostate cancer screening: This group takes only the position that men over age 75 should not be screening for prostate cancer with the PSA test. I encourage the more straight forward recommendation of the United States Preventive Services Task Force--that no man, at any age, should be routinely screened for prostate cancer with a PSA test.

     Here I describe only a handful of the 34 tests covered in the report. But these are the most common ones. If we learn to use these tests correctly, we will solve a lot of the problem. A patient should: "Think not what these tests can do for the physician, but what these tests can really do for you!"

REFERENCE: Qaseem A et al. Appropriate use of screening and diagnostic tests to foster high-value, cost-conscious care. Annals of Internal Medicine 2012; 156:147-9.