Tests may be needed to assess a person's intelligence or understanding and to determine their competency to refuse or consent to treatment. If decision making is affected by psychosis or peculiarities of personality, personality testing may likewise contribute to the analysis of some cases. Peer Reviewed Competency Assessments
What is the right to refuse or accept treatment?
Doctors, patients' relatives and, in contested cases, the courts have to decide, where someone's right to accept or refuse treatment is in doubt, whether that person's mental capacity is sufficient for legal competence and their stated wishes should therefore be respected.
Are seriously medically ill patients who refuse life-saving treatment mentally competent?
Results: Over the past 20 years, the burden of proof concerning the mental competence of seriously medically ill patients who refuse lifesaving treatment has shifted to the persons who seek to override these refusals.
How do you determine if a patient is legally competent?
Deciding whether someone is legally competent to make decisions regarding their own treatment requires an assessment of their mental capacity. The assessed capacity required for legal competence increases with the seriousness of what is at stake. The usual explanation is that patient autonomy is being balanced against best interests.
Can a patient's desire to die be evidence of impaired capacity?
However, in psychiatry a patient's desire to die is generally considered to be evidence of an impaired capacity to make decisions about lifesaving treatment. This contrast between ethical traditions is brought into clinical focus during the evaluation and treatment of medically ill patients with depression who refuse lifesaving treatment.
What competency is related to the right to refuse treatment?
Common law dictates that individuals possess autonomy and self-determination, which encompass the right to accept or refuse medical treatment.
How do you determine if a patient is competent?
In addition to performing a mental status examination (along with a physical examination and laboratory evaluation, if needed), four specific abilities should be assessed: the ability to understand information about treatment; the ability to appreciate how that information applies to their situation; the ability to ...
Can competent patients refuse medical treatment?
Competent patients have a right to refuse treatment. This concept is supported not only by the ethical principle of autonomy but also by U.S. statutes, regulations and case law. Competent adults can refuse care even if the care would likely save or prolong the patient's life.
What do you do when a patient refuses treatment?
If your patient refuses treatment or medication, your first responsibility is to make sure that he's been informed about the possible consequences of his decision in terms he can understand. If he doesn't speak or understand English well, arrange for a translator.
Who decides if a patient is competent by what criteria is this decision made?
Competency is a global assessment and legal determination made by a judge in court. Capacity is a functional assessment and a clinical determination about a specific decision that can be made by any clinician familiar with a patient's case.
Who can determine if a patient is competent to act on their own behalf?
So who determines whether a person is “competent” when signing the form? According to California Powers of Attorney and Health Care Directives, published by CEB, the attorney representing a principal in the drafting of a DPOA for financial management typically determines the mental capacity of the client.
Should a competent patient have the right to refuse a treatment?
Every competent adult has the right to refuse unwanted medical treatment. This is part of the right of every individual to choose what will be done to their own body, and it applies even when refusing treatment means that the person may die.
How do you document patient refusal?
DOCUMENTING INFORMED REFUSALdescribe the intervention offered;identify the reasons the intervention was offered;identify the potential benefits and risks of the intervention;note that the patient has been told of the risks — including possible jeopardy to life or health — in not accepting the intervention;More items...
What determines decision making capacity and competence?
Capacity is the basis of informed consent. Patients have medical decision-making capacity if they can demonstrate understanding of the situation, appreciation of the consequences of their decision, and reasoning in their thought process, and if they can communicate their wishes.
What is the correct procedure for refusal of medication?
Possible action that can be taken Patient refuses medication • Try to identify why the resident has refused the medication, their beliefs, understanding of what the medicine is for and consequences of not taking the medication. Establish if there is a pattern of refusal. Address any issues identified.
When documenting that a patient has refused a treatment you should include?
Terms in this set (15)Documentation of the refusal of treatment should include: ... Informed consent upholds the ethical principle of. ... informed consent involves telling the patient: ... Signing the Notice of Privacy Protection as mandated by HIPAA is the same as signing an informed consent document for treatment.More items...
What is the nurse's legal and ethical responsibilities toward the patient who refuses medical care or treatment?
All clients have the legal right to autonomy and self-determination to accept or reject all treatments and interventions. With the exception of emergencies, all aspects of nursing care and interventions must be explained to the patient.
Who should be responsible for the evaluation of a patient's competence?
The attending physician should be responsible for the evaluation of a patient's competence. It is the attending physician who should have the best knowledge of the patient's situation, prognosis, course of disease, information received, previous decision-making capacity and previously stated health care preferences.
How to prevent incompetent patients from directing their own treatment?
One way to avoid mistakenly preventing competent patients from directing the course of their own treatment while protecting incompetent individuals from the harmful effects of their decisions is for physicians to determine and document each patient's capacity for decision-making before a decision is manifested. This may prevent the physician from being biased toward a declaration of incompetence in those patients who do not comply with the recommended treatment.
When is Competence Questioned?
Decision-making capacity is not often questioned at the two extremes of the fully conscious and rational patient, on the one hand, and the unconscious or totally confused and disoriented patient on the other.
What is the importance of physician evaluation of patient competence?
Valid informed consent requires that the patient be competent to make medical decisions.
Why should patients be evaluated for decision making capacity?
Patients who appear competent as well as those who seem to be incompetent should be evaluated for decision making capacity in order to preserve the competent patient's right to autonomy and to protect the incompetent patient's well-being. Physicians frequently assess patient competence.
What is the duty of a physician to inform the patient about the recommended care?
A patient's right to decide whether or not to submit to medical treatment establishes a corresponding duty for the physician to inform the patient about the recommended care. A physician may be liable for negligence if he or she fails to secure the patient's informed consent or fails to inform the patient about the consequences of refusing treatment.
What is the doctrine of informed consent?
The principles underlying the doctrine of informed consent are based in early Anglo-American law regarding assault and battery. By definition, the intentional touching of another in a harmful or offensive manner without expressed consent is battery; the placing of someone in fear of being touched is assault.
How to assess a patient's condition?
Making certain that a patient understands his or her condition can be best assessed by open-ended inquiry, for example, “Can you tell me what your medical problem(s) consists of?” or “Why have you been brought to the hospital?” Avoid questions that elicit a yes or no reply, e.g., “Do you understand what your medical condition is?” since an affirmative reply does not clearly convey that the person comprehends the nature of the illness.
What is competency in law?
Competencyis a legal term referring to individuals “having sufficient ability… possessing the requisite natural or legal qualifications” to engage in a given endeavor.2(p257)Unfortunately, this definition is a broad concept encompassing many legally recognized activities, such as the ability to enter into a contract, to prepare a will, to stand trial, to make medical decisions, and so on. The definition, therefore, must be clarified depending on the issue in question. Simply put, competency refers to the mental ability and cognitive capabilities required to execute a legally recognized act rationally.3The determination of incompetence is a judicial decision, i.e., decided by the court. An individual adjudicated by the court as incompetent is referred to as de jure incompetent. After determining that the de jure incompetent cannot make prudent decisions in his or her own best interest, the court will assign a guardian to make decisions on the person's behalf.4,5
Why is incompetency considered labor intensive?
Because an adjudication of incompetency effectively denies an individual autonomy to make decisions, such court cases become labor intensive. An individual is presumed to be competent unless demonstrated to be otherwise. The standard of proof required for judicial finding of incompetency is that of “clear and convincing evidence.”6This standard of proof, based on evidence presented by licensed health care practitioners and others, is set at a standard between the high level of proof required for criminal convictions, i.e., “beyond a reasonable doubt,” and the lowest standard of “preponderance of the evidence.”7
What is the mental status test?
Often, psychiatrists will conduct a mental status examination, such as the Folstein Mini-Mental Status Examina tion,32the Short Portable Mental Status Question naire,33and the Cognitive Capacity Screening Examination,34to have a more formal measure of the patient's ability to manipulate information. Such tests measure cognitive abilities, but not decision-making capacity. Scores yielded by such instruments provide an indication of severity of dementia, but cannot yield a score for and lack sufficient sensitivity for decision-making capacity.35,36It is possible that an educationally disadvantaged person scoring poorly on the Mini-Mental Status Examination or alternative test can retain an ability to make treatment decisions, while a highly educated person adept at responding to the test's questions can fail to make prudent treatment decisions.37Dementia and cognitive deficits, e.g., mild mental retardation, may not necessarily preclude decision-making capacity.38
What are systemic lines of inquiry?
Systematic lines of inquiry can tap into risks and benefits, for example, “What can happen to you if you have the surgery?” “What is your understanding of the side effects of this particular medication?” or “The proposed test carries some risks; can you indicate what they are?” Frame questions assessing the benefits of the proposed interventions in a similar fashion and attend to the patient's understanding of probabilities of favorable or unfavorable outcomes.26Patients may well understand the reasons for the proposed procedure and how it is conducted, but may distort the likelihood of success or deny likely untoward or adverse consequences.
What is appreciation assessment?
The concept of appreciation is a rather individualized component of the capacity assessment. Assessment of the patient's ability to appreciate is not based upon the comparison of the patient's expressed wishes against the standard of what most reasonable persons would endorse in that situation. It does involve an appreciation of how the individual values each risk and benefit of the proposed treatment in question. Severe denial as a defense mechanism, delusions, or other psychotic processes can impair appreciation.30,31
What is capacity in medical terms?
Capacity refers to an assessment of the individual's psychological abilities to form rational decisions, specifically the individual's ability to understand, appreciate, and manipulate information and form rational decisions. The patient evaluated by a physician to lack capacity to make reasoned medical decisions is referred to as de facto incompetent, i.e., incompetent in fact, but not determined to be so by legal procedures. Such individuals cannot exercise the right to choose or refuse treatment, and they require another individual, a de facto surrogate, to make decisions on their behalf.
What are the two considerations that affect the degree to which the level of capacity required for competence varies in response to?
Two other considerations seem further to affect the degree to which the level of capacity required for competence varies in response to what is at stake. Medical ethics. The principle of beneficence includes injunctions not to do harm, to prevent evil or harm, to remove evil or harm and to promote good.
What happens if there is a principle that operates to raise the threshold level of mental capacity required for legal competence?
If there is a principle that operates to raise the threshold level of mental capacity required for legal competence, therefore, the operation of that principle may be limited at extremes of capacity and gravity. The practical consequences have not been described systematically.
What is the degree to which the threshold level of capacity necessary for legal competence varies in proportion to what is at stake?
The degree to which the threshold level of capacity necessary for legal competence varies in proportion to what is at stake is limited, it was suggested in the first section, by the effect of thresholds. There comes a point when someone's capacity is such that the law will regard him or her as legally competent, whatever the consequences. Two other considerations seem further to affect the degree to which the level of capacity required for competence varies in response to what is at stake.
What are the implications of leaving room for error?
The implications for clinical practice of leaving room for error seem to be different from those that follow from balancing best interests and autonomy. For example, additional information confirming a previously assessed level of capacity could lead to a patient's being found competent to manage his or her own affairs in circumstances where, in the absence of such additional information, the combination of the gravity of the consequences and uncertainty regarding the patient's competence would have led to that person being judged not competent. In other words the source and level of doubt attaching to any conclusion regarding capacity should form part of any evidence going to legal competence since it will contribute to the subsequent adjudication of that competence. The approach has an analogy in medical statistics. Instead of simply a mean, what is being required of doctors is a mean and standard deviation.
What does it mean to raise the threshold level of competence?
Raising the threshold level of capacity required for competence when the anticipated harm is greatest stems , by this argument, from a clinician's or a court's wish to be more certain.45,49It means leaving a greater margin for error when the consequences are serious (Figure 2).50,51Raising the threshold, of course, also increases the number of instances in which people are incorrectly assessed as not legally competent. Harm is then being done because their autonomous wishes are not respected. This is a different type of harm from that of failing to act in someone's best interests. Advocates of a 'margin-for-error' approach have to assume that it does not increase in severity in response to what is at stake or, if it does so increase, that it does not do so as much.
What is the assessment of mental capacity?
Deciding whether someone is legally competent to make decisions regarding their own treatment requires an assessment of their mental capacity. The assessed capacity required for legal competence increases with the seriousness of what is at stake.
What is the usual explanation for patient autonomy?
The usual explanation is that patient autonomy is being balanced against best interests. An alternative explanation, that we require greater room for error when the consequences are serious, implies a change to clinical practice and in the evidence doctors offer in court. INTRODUCTION. When a patient refuses medical treatment, the law in the UK, ...
What does "incompetent" mean?
incompetent, the request of a thoughtful and reflective terminally ill
Who wrote the 13Health matrix297?
Martin T. Harvey, Adolescent Competency and the Refusal of Medical Treatment, 13Health Matrix297 (2003)
Is Case Western Reserve University in the Health Matrix?
It has been accepted for inclusion in Health Matrix: The Journal of Law-Medicine by an authorized administrator of Case Western Reserve University
Definition
Background
- People are legally presumed to have the capacity to make decisions for themselves unless they have been formally judged to be incompetent. Competent adult patients have the legal right to refuse medical treatment. This legal right, with its origins in the constitutional right to privacy, was confirmed by the Superior Court of California in Barber,9...
Significance
- The problem raised by the incompetency exception to informed consent is that of specifying the circumstances in which the exception applies. In order to specify these circumstances, incompetency must be defined. Unfortunately, there is no single or well-accepted definition of incompetence.17,,18 The criteria selected for the determination of competence should promote …
Categories
- The various approaches to the determination of competency may be divided into five categories. These are: 1) expressing a choice; 2) choice with a reasonable outcome; 3) choice based on rational reasons; 4) ability to understand; and 5) appreciation of the situation and its consequences.4 The first test, with its reliance on the capability to communicate a choice, is th…
Purpose
- The rational reasons test of competency examines the nature of the decision-making process. It determines how the patient assimilates the necessary information into the decision-making process.20 The ability to manipulate information rationally requires the capacity to use logical processes to compare the benefits and risks of various treatment options. The patient must be …
Introduction
- The test that is applied in practice combines elements of all of these approaches. The circumstances in which competency becomes an issue determine which elements of which tests are stressed.17 Incompetency may be either specific or general. The determination of specific incompetency renders the person incompetent only for the specified purposes (eg, medical deci…
Assessment
- The flaw in this approach is that there may be little correspondence between the determination of general incompetency and the patient's ability to participate in medical decision-making. The best approach would be to use the general incompetency standard as a threshold test for incompetency. Then, if the patient is determined to be generally competent, the physican must a…
Example
- An example of a class of mentally ill patients in whom competence should be questioned are those whose delusional thinking results in them not being able to agree that the proposed treatment would have any relevance for them because they do not envision themselves as ill. In these patients, cognitive understanding is an insufficient measure of capacity for interpreting th…
Management
- Decision making capacity does not necessarily remain stable over time. Competence may fluctuate as a function of medications, fatigue, pain, the course of the illness or psychodynamic factors. Consent obtained during intermittent periods of lucidity should be honored.1,,26 This principle was upheld by the Bartling court: The fact that Mr. Bartling periodically wavered from t…
Qualification
- The determination of incompetency theoretically requires the official legal act of adjudication. A determination that an individual patient lacks the capacity to make some or all medical decisions is, however, customarily carried out extra-judicially and is only rarely reviewed in court.5,,16 The treating physician will determine, initially, whether there are such doubts about a patient's comp…
Status
- The concluding remarks confirm this opinion, By the above ruling we do not intend to be understood as implying that a proceeding for judicial declaratory relief is necessarily required for the implementation of comparable decisions in the field of medical practice.27 The Barber and Bartling courts support this position. According to the Bartling opinion, in future similar situation…
Criticism
- The judicial system does not provide the ideal forum in which to make medical decisions. The mere logistics of obtaining judicial review argue against it. The legal process is cumbersome and time consuming and the adversarial judicial system may polarize physicians and families, undermining trust.15 Judicial review may not confer the immunity from legal liability that some …