Capacity

To have capacity a patient must demonstrate the ability to:

  1. Understand the decision that needs to be made
  2. Retain the information long enough to make the decision
  3. Weigh up the options and implications of choosing each option
  4. Communicate their decision

In Australia, capacity assessment by General Practitioners (GPs) involves evaluating a patient’s ability to make informed decisions about their own medical treatment, personal affairs, and financial matters. This process is important, especially for patients who may have cognitive impairments, mental health issues, or other conditions that could affect their decision-making abilities. Here’s an outline of how capacity assessment is typically conducted:

1. Initiating the Assessment

  • Reason for Assessment:
    • Identify the reason for the capacity assessment.
    • This could be due to concerns raised by family members, changes in the patient’s behaviour, or during routine medical evaluations.
  • Consent:
    • Ensure that the patient consents to the assessment.
    • If the patient’s capacity to consent is in question, the GP may need to proceed with caution and seek guidance from legal or medical ethics bodies.

2. Clinical Interview

  • Medical History:
    • Review the patient’s medical history, including any diagnoses that might affect cognitive function (e.g., dementia, psychiatric disorders, neurological conditions).
  • Current Medications:
    • Evaluate the impact of current medications on cognitive abilities.
  • Symptom Assessment:
    • Discuss any symptoms the patient is experiencing that could affect capacity, such as memory loss, confusion, or changes in mood or behaviour.

3. Cognitive Testing

  • Standardized Tests (MMSE, RUDAS, MoCA, GPCOG, GDS):
    • Utilize standardized cognitive assessment tools such as the Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), or General Practitioner Assessment of Cognition (GPCOG).
  • Task Performance (Clock Drawing, Maze Test):
    • Observe the patient’s ability to perform specific tasks or follow instructions
    • This can provide insights into their cognitive function.
    • Clock drawing and the Maze test are two common examples.

4. Functional Assessment

  • Daily Living Activities:
    • Evaluate the patient’s ability to perform activities of daily living (ADLs) and instrumental activities of daily living (IADLs), such as managing finances, cooking, and personal hygiene.
  • Social and Occupational Functioning:
    • Assess the impact of any cognitive impairment on the patient’s social interactions and ability to work or volunteer.

5. Decision-Making Abilities

  • Understanding:
    • Determine if the patient understands the information relevant to the decision at hand.
    • Assess whether the patient appreciates the significance of the information and its implications for their situation.
  • Retention:
    • Ensure the patient can retain the required information for long enough to make a decision
  • Weigh Up (Reasoning):
    • Evaluate the patient’s ability to weigh options and consider consequences.
  • Communication:
    • Ensure the patient can communicate their decisions effectively.

6. Collateral Information

  • Family and Caregivers:
    • Gather information from family members, caregivers, and others who know the patient well to corroborate findings.
  • Medical Records:
    • Review previous medical records for consistency and additional insights.

7. Documentation and Reporting

  • Detailed Notes:
    • Document all findings from the assessment thoroughly, including the tools used, observations made, and the rationale for the conclusions drawn.
  • Formal Report:
    • If required, prepare a formal report summarizing the assessment and its findings, especially if it will be used for legal or administrative purposes.

8. Legal and Ethical Considerations

  • Legal Standards:
    • Be aware of and adhere to the legal standards for capacity in the relevant Australian jurisdiction.
  • Ethical Guidelines:
    • Follow ethical guidelines to ensure the assessment is conducted with respect, confidentiality, and fairness.

9. Follow-Up and Support

  • Interventions:
    • Recommend appropriate interventions or supports if capacity is found to be impaired, such as the involvement of social services, legal guardianship, or enduring power of attorney.
    • De-prescribe medications that may have an adverse impact on capacity.
  • Reassessment:
    • Schedule follow-up assessments as necessary, particularly if the patient’s condition is expected to change over time.

Capacity assessment by GPs in Australia is a thorough and multi-faceted process that balances medical, cognitive, and functional evaluations with legal and ethical considerations to ensure that patients are supported in their decision-making abilities.