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3 Fitzgerald Health Education Associates, Inc., August 2015 fhea.com Four abilities are commonly assessed when determin- ing decision-making capacity: the ability to receive, process, and understand the relevant information; to ap- preciate the situation and its consequences; to rationally process the information; and to express a choice. 1,2 Understanding This is assessed by asking a patient to explain in his or her own words an understanding of their condi- tion, what the treatment or diagnostic test involves, including the recommended intervention, its poten- tial risks and benefits, the probability that treatment will be successful, other possible treatments, and the potential risks and benefits of forgoing treatment. 1,3 Appreciation The ability of a patient to appreciate how the informa- tion provided by the clinician applies to her situation is assessed by asking what she really believes about her medical condition, why the clinician has recommended the intervention, whether she believes she needs the recommended intervention, what she thinks will hap- pen if she forgoes the intervention, and why the clini- cian has recommended the intervention. 1,3 Reasoning A patient's ability to rationally consider the informa- tion provided by the clinician can be determined by asking how he made his choice to accept or reject treatment, what factors he considered in making his choice, and how he balanced the various factors when making his decision. 1 Express a Choice The ability to express a choice can be assessed by ask- ing the patient to indicate her decision on whether to proceed with the suggested treatment. 1 This decision should be relatively stable over time, but changing this decision does not necessarily indicate compro- mised decision-making capacity as long as the pa- tient can explain the rationale for the change. 2 When is assessment necessary? In practice, clinicians assume that adults are capable of making decisions unless there is substantial evi- dence suggesting otherwise. Decision-making capac- Certification Q&A; Continued on page 5 C ontinued from page 1 Does This Patient Have the Capacity to Decide Against Treatment? Four abilities are commonly assessed when determining decision-making capacity: • the ability to receive, process, and understand the rele- vant information; • the ability to express a choice; • the ability to appreciate the situation and its conse- quences; and • the ability to rationally process the information. CASE A 90-year-old woman with moderate dementia, heart fail- ure, and chronic renal insufficiency presents with new- onset weakness. Further evaluation reveals marked hyper- kalemia (eGFR = 22 mL/min/1.73 m 2 ). A nephrologist recommended the patient receive he- modialysis. When discussing this option with the patient, she declined the treatment. When asked why she does not want dialysis, she stated, "I do not want to be on a ma- chine. I am quite old and my health is not good." The patient was asked what she believed would happen if she did not have dialysis. She stated, "I guess I will die. That is OK." In addition to the clinical assessment, a formal assess- ment was performed because of the patient's moderate de- mentia. Several instruments were used to conduct a struc- tured assessment, including the Capacity to Consent to Treatment Instrument (CCTI). During the formal assessment, the patient inaccurately reported the current year, her loca- tion, and the name of the president of the United States. From the information provided, does this patient have the capacity to decide against dialysis? This patient does have the capacity to decide against dial- ysis. The patient understood why she needed dialysis, clearly stated why she did not want dialysis, and under- stood the consequences of not having it.