A Primer On Capacity

Written By: W. Howard Buddin Jr., Ph.D. & S. Marc Testa, Ph.D.
Published On: 07/24/2014

At some point in your career, you will likely be asked to evaluate a patient’s capacity for medical and/or financial decision-making. Broadly speaking, the definition of capacity for decision-making is one centered around:

An individual’s ability to make reasoned decisions about their healthcare and estate.

The definition is easy to learn and makes logical sense, right? Understanding when, how, why, etc., to evaluate for identification of capacity, though, is an entirely separate thing, quickly becoming nuanced and complex. So much so, that given any randomly selected group of healthcare professionals, picking one to lead the team on identification of a person’s capacity becomes a game of “not it.”

Importantly, the descriptors capacity for decision-making and legal competency are sometimes used interchangeably, but must not be used in such a way; they are decidedly not the same. Basically, legal competency is a decision rendered by a court of law. Capacity for decision-making informs that decision, and is rendered by the clinician.

Lack of Capacity: Not Just a Bad Idea

To say that an individual lacks capacity for reasoned decision-making is not the same thing as saying that they make bad choices. It’s not even the same as saying that they make terrible choices. Making terrible choices is somewhat normative, after all. Indeed, if making a few bad choices was sufficient to meet criteria for lack of capacity, then, let’s face it, we would all lack capacity at some point(s) in time.

Instant Carma

Let’s look at the cases of two individuals, who have ultimately made an identical decision: buy a new car. The reasoning behind each of their decisions, though, might elude a cursory investigation. Next, we will look at the information that was obtained during clinical interview. The purpose of the clinical interview in each case will be to elicit the reasoning behind each person’s choice or choices. This process is absolutely critical; it is how, as clinicians, we determine whether there is a lack of capacity or not. Again, and this point cannot be overstated, the final outcome (i.e., the decision that someone makes) has almost nothing to do with our decision regarding capacity.

Please note:

  1. These case examples are entirely fictional
  2. Examples are intentionally basic and sanitized of lots of the real-world variables we often encounter. This is a primer, after all. We will come up with more complex and complicated examples in a second article.

The Setting

A 73-year-old man has decided that he would like to purchase a car. His primary source of income is Social Security. He is not “wealthy,” per se, but he has a non-trivial amount of money in savings. While much of his finances are not liquid, he does keep several thousand dollars hidden in his house. He uses a portion of this to pay for his car. His adult son and daughter brought him to see his primary care physician.

Okay, now that the framework is laid, let’s split this story in two:

Rationale 1:

The man owns a car; however, his car is not running well on most days. On some days, he is unable to start the car at all. He makes regular trips to the grocery store and to a friend’s house, and plays an occasional round of golf. He reasons thatin order to keep doing these things, and maintain his quality of life, he needs a new vehicle. He adds that the ongoing maintenance of his car over the years has risen to the point where it would be unwise to continue fixing the car versus simply purchasing a new, functional vehicle. His adult son and daughter say that he can keep doing these things by either using public transportation or waiting for them to take him wherever he needs to go.

Rationale 2:

The man owns a car, but “it doesn’t run,” he reports. “I needed a new car,” is as far as he is able to “rationalize” his purchase. His adult son and daughter tell you that his car “doesn’t run” because they took his keys away over six months ago. His driver’s license has been suspended, as well. Before these things happened, he had been in two verified, minor car accidents, and was frequently getting lost while trying to drive to familiar places.

These examples show us how two people can make the same decision, though only the first person uses sound reasoning. The second individual demonstrates a patent lack of reasoning, while simultaneously showing confusion and a lack of awareness for his situation.

Capacity is the Mother of Intervention

The identification of someone’s capacity for decision-making, and the concomitant issues, might be among the greater services and interventions that neuropsychologists can offer. After the lack of capacity is established, we can then advise the patient and/or the patient’s caregivers on what level of care the patient requires, whether lack of capacity might be temporary, and whether they need to execute Durable Power of Attorney, if one exists.

Learning what capacity for decision-making means and how to identify it is a clinical skill worth learning and honing. For further reading, we suggest the following:

Appelbaum, P.S., & Grisso, T. (1988). Assessing patient’s capacities to consent to treatment. New England Journal of Medicine (319), 1635–1638.

Searight, H. Russell & Hubbard, Susan L. (1998) Evaluating patient capacity for medical decision making: Individual and interpersonal dimensions. Families, Systems & Health 16(1/2), 41–54.

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