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Decision-making capacity: from testing to evaluation

Abstract

Decision-making capacity (DMC) is the gatekeeping element for a patient’s right to self-determination with regard to medical decisions. A DMC evaluation is not only conducted on descriptive grounds but is an inherently normative task including ethical reasoning. Therefore, it is dependent to a considerable extent on the values held by the clinicians involved in the DMC evaluation. Dealing with the question of how to reasonably support clinicians in arriving at a DMC judgment, a new tool is presented that fundamentally differs from existing ones: the U-Doc. By putting greater emphasis on the judgmental process rather than on the measurement of mental abilities, the clinician as a decision-maker is brought into focus, rendering the tool more of an evaluation guide than a test instrument. In a qualitative study, the perceived benefits of and difficulties with the tool have been explored. The findings show on the one hand that the evaluation aid provides basic orientation, supports a holistic perspective on the patient, sensitizes for ethical considerations and personal biases, and helps to think through the decision, to argue, and to justify one’s judgment. On the other hand, the room for interpretation due to absent operationalisations, related ambiguities, and the confrontation with one’s own subjectivity may be experienced as unsettling.

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Notes

  1. When patients are judged to be incompetent their will is still relevant. However, decision making will be guided by their will as previously expressed in advance directives or as presumed by surrogates. The patient may be consulted about the decision that needs to be taken but will at this point not have the authority (and responsibility) to make the decision him- or herself. .

  2. „U” stands for the Swiss German term „Urteilsfähigkeit“(decision-making capacity).

  3. The tool was developed alongside guidelines on the evaluation of decision-making capacity in medical practice issued by the Swiss Academy of Medical Sciences in 2019 and is consistent with the guidelines’ set of core principles (cf. https://www.samw.ch/en/Publications/Medical-ethical-Guidelines.html).

  4. The U-Doc has been included in the official guidelines on DMC published 2018 by the Swiss Academy of Medical Sciences (SAMS): https://www.samw.ch/de/Ethik/Autonomie-in-der-Medizin/Beurteilung-der-Urteilsfaehigkeit.html (last accessed on March 31, 2019).

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Acknowledgements

The authors would like to thank all partners and collaborators in the project as well as workshop participants and the commission members of the Swiss Academy of Medical Sciences, who gave valuable comments on different draft versions of the tool. We are also grateful to Mona Neubauer, Marco Ehrenmann, Jon Wirthner, and Nadja Müller for layouting and co-designing the form.

Funding

The paper has arisen in the context of a research project on „Decision-Making Incapacity at the End of Life and its Assessment in Switzerland funded within the National Research Programme NRP 67 “End of life” of the Swiss National Science Foundation (SNF-Grant 406740_139294).

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Correspondence to Nikola Biller-Andorno.

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Hermann, H., Feuz, M., Trachsel, M. et al. Decision-making capacity: from testing to evaluation. Med Health Care and Philos 23, 253–259 (2020). https://doi.org/10.1007/s11019-019-09930-6

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Keywords

  • Competence
  • Decision-making capacity
  • Tool
  • Documentation
  • Evaluation
  • Ethics