Comments on: Medical decision-making competence http://www.journalclub.org/2004/10/19/n6 Comments on the medical literature Wed, 13 Jul 2005 13:30:08 +0000 hourly 1 http://wordpress.org/?v=3.0.1 By: Beth Leopold http://www.journalclub.org/2004/10/19/n6/comment-page-1#comment-843 Beth Leopold Wed, 23 Feb 2005 00:09:59 +0000 http://www.journalclub.org/2004/10/19/n6#comment-843 I'm a public health professional who discovered this discussion by accident while looking for something else, but I just have to comment. I've had regular medical decision-making experience as a patient with a fairly obscure neurological pain syndrome and while supporting both parents through their final illnesses. I'm facinated by this detached discussion of competency of patients to make medical decisions. In my experience most high-stakes medical choices are offered to patients verbally, without well prepared written, objective information, in an atmosphere highly charged with emotion, by medical professionals who have not been evaluated on their communication skills. My observation is that doctors, who have the advantage of years of study and preparation, are quite willing to make the easy decisions. The more risky the choices, the more the decision shifts to patient and family. The most common example is choice of medication in this environment of heavy medication marketing. Doctors seldom discuss the full range of meds and offer me choices. The way I get a choice is after I develop a reaction to the popular med, then I'm offered the old stand-by. But my favorite example is when I had to fight to keep my dad from being moved from a step-down unit to a med-surg floor after he showed a modest post-surgical improvement. My argument was that, in my judgement, the improvement wasn't well enough established for the careful supervision and observation which is characteristic of the step-down unit to be discontinued. I was told as a family member, I wasn't qualified to make that decision. Funny how I became qualified to make end of life decisions about my dad within the week. I’m a public health professional who discovered this discussion by accident while looking for something else, but I just have to comment. I’ve had regular medical decision-making experience as a patient with a fairly obscure neurological pain syndrome and while supporting both parents through their final illnesses. I’m facinated by this detached discussion of competency of patients to make medical decisions. In my experience most high-stakes medical choices are offered to patients verbally, without well prepared written, objective information, in an atmosphere highly charged with emotion, by medical professionals who have not been evaluated on their communication skills.

My observation is that doctors, who have the advantage of years of study and preparation, are quite willing to make the easy decisions. The more risky the choices, the more the decision shifts to patient and family. The most common example is choice of medication in this environment of heavy medication marketing. Doctors seldom discuss the full range of meds and offer me choices. The way I get a choice is after I develop a reaction to the popular med, then I’m offered the old stand-by. But my favorite example is when I had to fight to keep my dad from being moved from a step-down unit to a med-surg floor after he showed a modest post-surgical improvement. My argument was that, in my judgement, the improvement wasn’t well enough established for the careful supervision and observation which is characteristic of the step-down unit to be discontinued. I was told as a family member, I wasn’t qualified to make that decision. Funny how I became qualified to make end of life decisions about my dad within the week.

]]> By: Matthew Hotopf http://www.journalclub.org/2004/10/19/n6/comment-page-1#comment-100 Matthew Hotopf Mon, 29 Nov 2004 13:35:00 +0000 http://www.journalclub.org/2004/10/19/n6#comment-100 [<strong>Author's comments</strong>] I'm flattered to see our paper highlighted here. The key point about capacity is that it is situation specific (ie "functional"). This is why the MacCAT-T is an appropriate interview to assess it and the Mini-Mental State Examination is not. The fear that the MacCAT-T will bias the study against people with "Crackpot" medical ideas, is misplaced. The interview allows a patient to make what many people would consider to be a foolish choice and still be rated as having mental capacity. It tests the process by which a choice is made and expressed, rather than the choice itself. The problem with simply using a measure like the MMSE is that it would rely on a "status" approach, whereby all individuals who scored below a given threshold would be deemed incapacitated, without taking into account the nature of the decision. This is a far more paternalistic approach than the "functional" one used in the MacCAT-T. Individuals with cognitive impairment are often perfectly capable of making relatively simple decisions, but may not be capable of making more complex ones (which, typically, includes many medical decisions which are heavy with appraisal of risks and benefits). Furthermore, mental capacity is more than just a cognitive phenomenon - in other words, there may be many factors which affect "appreciation" which are not to do with the mechanics of memory and comprehension. The simplest example is the effect psychosis has on mental capacity - an individual may have a delusional belief that doctors are attempting to poison him, and therefore refuse treatment for a psychotic disorder. The same individual may well have excellent cognitive functioning. Appreciation may also be affected by affective disorders (depression and mania) and even powerful emotions in an individual with an adjustment disorder. [Author's comments]

I’m flattered to see our paper highlighted here. The key point about capacity is that it is situation specific (ie “functional”). This is why the MacCAT-T is an appropriate interview to assess it and the Mini-Mental State Examination is not. The fear that the MacCAT-T will bias the study against people with “Crackpot” medical ideas, is misplaced. The interview allows a patient to make what many people would consider to be a foolish choice and still be rated as having mental capacity. It tests the process by which a choice is made and expressed, rather than the choice itself.

The problem with simply using a measure like the MMSE is that it would rely on a “status” approach, whereby all individuals who scored below a given threshold would be deemed incapacitated, without taking into account the nature of the decision. This is a far more paternalistic approach than the “functional” one used in the MacCAT-T. Individuals with cognitive impairment are often perfectly capable of making relatively simple decisions, but may not be capable of making more complex ones (which, typically, includes many medical decisions which are heavy with appraisal of risks and benefits).

Furthermore, mental capacity is more than just a cognitive phenomenon – in other words, there may be many factors which affect “appreciation” which are not to do with the mechanics of memory and comprehension. The simplest example is the effect psychosis has on mental capacity – an individual may have a delusional belief that doctors are attempting to poison him, and therefore refuse treatment for a psychotic disorder. The same individual may well have excellent cognitive functioning. Appreciation may also be affected by affective disorders (depression and mania) and even powerful emotions in an individual with an adjustment disorder.

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