Determination of Decision-Making Capacity

  • Robert Allan Pearlman


Decision-making capacity is a central determinant of an older person’s ability to direct her care. When decision-making capacity exists, a patient or nursing home resident should engage fully in the process of informed consent to recommended treatment or diagnostic interventions. In addition, she may develop advance directives, refuse life-sustaining treatment, and exercise the personal freedoms guaranteed in our society. When decision-making capacity does not exist, however, the older person’s ability to exercise her autonomy or right to self-determination is severely compromised. Decision making often continues without the direct involvement of the mentally incapacitated person, usually by having either a family member or a designated proxy act as the surrogate decision maker.1


Advance Directive Ethic Consultation Surrogate Decision Maker Treatment Refusal Make Health Care Decision 
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  1. 1.
    Buchanan A, Brock D. Deciding for Others. New York: Cambridge University Press; 1989: 58.Google Scholar
  2. 2.
    Sullivan M, Youngner S. Depression, competence, and the right to refuse lifesaving medical treatment. Am J Psychiatry. 1994; 151: 971–978.PubMedGoogle Scholar
  3. 3.
    Bursztajn, H, Harding H, Gutheil T, et al. Beyond cognition: the role of disordered affective states in impairing competence to consent to treatment. Bull Am Acad Psychiatry Law. 1991; 19: 383–388.PubMedGoogle Scholar
  4. 4.
    Kloezen S, Fitten L, Steinberg A. Assessment of treatment decision-making capacity in a medically ill patient. J Am Geriatr Soc. 1988; 36: 1055–1058.PubMedGoogle Scholar
  5. 5.
    President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Making Health Care Decisions. Washington, DC: US Government Printing Office; 1982.Google Scholar
  6. 6.
    Kutner J, Ruark J, Raffin T. Defining patient competency for medical decision making. Chest. 1991; 100: 404–409.CrossRefGoogle Scholar
  7. 7.
    Emanuel E, Emanuel L. Proxy decision making for incompetent patients-an ethical and empirical analysis. JAMA. 1992; 267: 2067–2071.PubMedCrossRefGoogle Scholar
  8. 8.
    Roth L, Meisel A, Lidz C. Tests of competency to consent to treatment. Am J Psychiatry. 1977; 134: 279–284.PubMedGoogle Scholar
  9. 9.
    Culver C, Gert B. The inadequacy of incompetence. Milbank Q. 1990; 68: 619–643.PubMedCrossRefGoogle Scholar
  10. 10.
    Folstein M, Folstein S, McHugh P. Mini Mental State: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975; 12: 189–198.PubMedCrossRefGoogle Scholar
  11. 11.
    Alexander M. Clinical determination of mental competence: a theory and a retrospective study. Arch Neurol. 1988; 45: 23–26.PubMedCrossRefGoogle Scholar
  12. 12.
    Appelbaum P, Grisso T. Assessing patients’ capacities to consent to treatment. N Engl J Med. 1988; 319: 1635–1638.PubMedCrossRefGoogle Scholar
  13. 13.
    Searight H. Assessing patient competence for medical decision making. Am Family Physician. 1992; 45: 751–759.Google Scholar
  14. 14.
    Jonsen A, Siegler M, Winslade W. Clinical Ethics. 3rd ed. New York: Macmillan; 1992.Google Scholar
  15. 15.
    Morreim E. Impairments and impediments in patients’ decision making: reframing the competence question. J Clin Ethics. 1993; 4: 294–307.PubMedGoogle Scholar
  16. 16.
    Venesy B. A clinician’s guide to decision making capacity and ethically sound medical decisions. Am J Phys Med Rehabil. 1994; 73: 219–226.PubMedCrossRefGoogle Scholar
  17. 17.
    Drane J. The many faces of competency. Hastings Cent Rep. 1985; 15: 17–21.PubMedGoogle Scholar
  18. 18.
    Silberfeld M, Nash C, Singer P. Capacity to complete an advance directive. J Am Geriatr Soc. 1993; 41: 1141 1143.Google Scholar
  19. 19.
    Ganzini L, Lee M, Heintz R. The effect of depression treatment on elderly patients’ preferences for life-sustaining medical therapy. Am J Psychiatry. 1994; 151: 1631–1636.PubMedGoogle Scholar
  20. 20.
    Lee M, Ganzini L. The effect of recovery from depression on preferences for life-sustaining therapy in older patients. J Gerontol. 1994; 49: M15–21.PubMedCrossRefGoogle Scholar
  21. 21.
    Bedell S, Delbanco T. Choices about cardiopulmonary resuscitation in the hospital: when do physicians talk to patients. N Engl J Med. 1984; 310: 1089–1093.PubMedCrossRefGoogle Scholar
  22. 22.
    Uhlmann R, Pearlman R, Cain K. Ability of physicians and spouses to predict resuscitation preferences of elderly patients. J Gerontol. 1988; 43 (5): M115–121.PubMedCrossRefGoogle Scholar
  23. 23.
    Schneiderman L, Kaplan R, Pearlman R, et al. Do physicians’ preferences for life-sustaining treatment predict their patients’ preferences for life-sustaining treatment? J Clin Ethics. 1993; 4 (1): 28–32.PubMedGoogle Scholar
  24. 24.
    Appelbaum P, Roth L. Clinical issues in the assessment of competency. Am J Psychiatry. 1981; 138: 1462–1467.PubMedGoogle Scholar
  25. 25.
    Appelbaum P, Roth L. Treatment refusals in medical hospitals. In: President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Making Health Care Decisions. Washington, DC: US Government Printing Office; 1982;2:411477.Google Scholar
  26. 26.
    Kapp M. Liability issues and assessment of decision-making capability in nursing home patients. Am J Med. 1990; 89: 639–642.PubMedCrossRefGoogle Scholar
  27. 27.
    Appelbaum P, Mirkin S, Bateman A. Empirical assessment of competency to consent to psychiatric hospitalization. Am J Psychiatry. 1981; 138: 1170–1176.PubMedGoogle Scholar

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© Springer Science+Business Media New York 1997

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  • Robert Allan Pearlman

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