Q: Can you explain the difference between patient capacity and competence, and what role does a case manager play in identifying these patients? Due to legal licensing issues, this assessment is not an appropriate task for nurses, licensed practical nurses, technicians or other support staff. Often, psychiatrists are seen as the experts in this assessment, and they may be involved in particularly complex situations that require expert advice. However, these providers are not always available for immediate advice. Therefore, and especially in the emergency room, due to the high visual acuity of physical or mental illnesses, a rapid assessment of capacity may be required immediately. Therefore, any physician, medical assistant or registered nurse can and should be able to assess and determine capacity. Therefore, the threshold of capacity required for legal jurisdiction must increase as the consequences worsen (Figure 1).37 On the other hand, “if there is little impact on decision-making,” “the level of decision-making capacity required [for a patient`s consent to be considered competent] can be reasonably reduced.” 38 Other authors point to the threshold that varies depending on the severity,27,36 of what is decided, how much the patient should lose36 or what is at stake.25 There are 4 main components of medical capacity: The usual conclusion that the amount of capacity required should vary in proportion to the severity of the consequences requires several limitations. First, the treatment of autonomy as primarily by law limits the application of this proportionality to persons with low capacity. Second, the most frequently advanced justification for proportionality, which balances autonomy and well-being, does not reflect the status accorded by law to patient autonomy. An alternative that reflects this status implies that current practice should change.
Third, ethical considerations and the widespread desire to limit the circumstances in which expressed wishes are not taken into account further limit the degree of capacity required for legal competence to be proportionate to the seriousness of the patient`s decision. Competence or competence is a legal term defined as a person`s ability to participate in legal proceedings, including their ability to make medical decisions. Jurisdiction is determined by a judge, not a doctor. The extent to which the threshold of jurisdiction required for jurisdiction varies in proportion to what is at stake is limited, as suggested in the first section by the effect of thresholds. There comes a time when a person`s capacity is such that the law considers him or her legally capable, regardless of the consequences. Two other considerations appear to have an additional impact on the extent to which the level of skill required varies depending on the issue. Despite our overall goal of respecting the ethical principles outlined in the Belmont report, this is not always possible. While physicians and other practitioners do provide medical care to patients, physicians have many other roles; e.g.
as a protector of hospital staff, guardian of public health, citizen, and a humanistic and spiritual being in its own right. In everyday clinical practice, certain situations arise that lead to conflicts between these roles and complicate the ethics of day-to-day decision-making in medical practice. For example, imagine that you have diagnosed a patient with active tuberculosis but they refuse treatment. In your role as a practitioner, you have a conversation with them about their refusal of treatment and decide that the patient has the capacity to refuse. They are therefore ethically required to respect the autonomy of this patient to make their own medical choices, but also to protect and serve the health of the entire community in terms of the risk of infectious contagion. How do you assess those competing interests? What legal consequences can you face if you take precedence over the other? Source: Ganzini L, Volicer L, Nelson WA, Fox E, Derse AR. Ten myths about decision-making. 2004;5(4):263-267. In light of this mental state review, it would be reasonable and appropriate to determine that this patient is incapable of making informed or logical medical decisions. Of the four capacity criteria listed above, he demonstrated none. A patient who does not have decision-making capacity cannot refuse or consent to treatment [7].
Once this lack of capacity has been determined and documented, the medical provider is legally authorized to perform sedation, restraint, venipuncture, and other tests or treatments deemed appropriate. The plaintiff in Re T was a Jehovah`s Witness who had received a blood transfusion when he was unable to give or withhold consent. The Court of Appeal considered whether life-threatening circumstances were relevant to determining whether the patient`s capacity was sufficient to comply with the refusal. He noted that they: Some specific triggers for further investigation of a patient`s decision-making capacity are [2][9][10][9]: However, it is also possible to formulate a threshold limiting proportionality in terms of capacity. Later in its judgment in Re B, the High Court stated: Remember that a tort is an act or omission of an act that causes harm or harm to a person. Specifically, with respect to the figure above, the common law offence of “assault” includes “an act or omission that causes a person to fear or apprehend with reason immediate assault.” Here, the battery is legally defined as a “harmful or offensive contact”. Does the IA location represent a battery? Similarly, the criminal act of “false detention” involves an act or omission that results in a person being “locked or tied up in a defined space with no possibility of escape”. Does the restraint and sedation of the patient constitute false imprisonment? Decision-making capacity and legal competence are terms that are often used interchangeably in a hospital to describe an individual`s ability to make coherent decisions about themselves, as an expression of autonomy, autonomy and respect for the patient`s right to self-determination. Medical ethics: basic principles.
Specifically, a patient`s ability to make autonomous decisions about their treatment is determined by a physician, while competence is a legal term that describes a person`s ability to participate in legal processes, as determined by a judge. These include the patient`s initial abilities, the current situation, and the severity of the possible consequences [11]. This is an examination that psychiatry, psychology and primary care providers can be aware of and comfortable with. Suppliers in other fields may have less experience with this assessment. Ideally, it should be practiced regularly so that it can be done quickly and correctly when needed. This process has been described as “a complex computation that includes mental state, cognitive abilities, culture, education, health literacy, and the ability to articulate issues of concern” [12]. Decision assessment should be integrated into every patient interaction. The depth of this assessment may vary from case to case, depending on (1) the severity of the disease, (2) the patient`s age and functional status, (3) the patient`s or family`s goals of care, (4) the clinical setting, or (5) a number of other factors. Keep in mind that a capacity assessment is only valid in the time, place, and situation in which the assessment took place.[8] It is therefore a snapshot and cannot be applied to any other time or situation. For example, a patient with a history of dementia does not automatically lack capacity.
At the time of assessing capabilities, they may be clear and able to meaningfully participate in the discussion, possibly indicating a decision-making capacity in the present moment. However, two weeks later, the same patient may be so disoriented that he is subsequently classified as incapable by examination.