Chapter

Values, validity, and ethical angst: assessment of mental capacity in older adults

Bret L. Hicken, Angela Plowhead and William Gibson

in Casebook of clinical geropsychology

Published on behalf of Oxford University Press

Published in print September 2010 | ISBN: 9780199583553
Published online February 2013 | e-ISBN: 9780191754678 | DOI: http://dx.doi.org/10.1093/med/9780199583553.003.0015
Values, validity, and ethical angst: assessment of mental capacity in older adults

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The evaluation of mental capacities can be challenging—the process is neither simple nor necessarily intuitive. Mental capacity is a multivariate concept rather than a single, unitary construct and capacities can be permanently or temporarily affected by a variety of circumstances, including psychiatric conditions. A capacity evaluation could also potentially infringe on patients’ civil rights, obligating family, providers, or society to act in a patient's behalf to prevent harm, which can result in some ethical angst on the part of the evaluator. The case scenarios above suggest several points that clinicians should consider to facilitate evaluating mental capacities:

◆ What accepted legal or clinical criteria for this mental capacity can inform the evaluation process? Capacity evaluation should be grounded in an underlying model. In doing so, the clinician minimizes the risk that the capacity determination will be based solely on particularly salient features about a patient (e.g. short-term memory deficits, dementia diagnosis, etc.). Instead, the evaluation will account for multiple relevant factors that should all be considered prior to making a determination. Using standard criteria also provides some legal protection to the clinician. In the absence of accepted standards, the clinician should obtain legal counsel prior to conducting an evaluation. ◆ What values and beliefs are at play in this case? The clinician should find out patients’ preferences and how their decisions are being influenced by the goals of family, friends, and providers. Perhaps most importantly, clinicians must be aware of their own biases and then take steps to minimize their impact on the evaluation. ◆ In what ways can the evaluation be supplemented in order to improve the reliability and validity of the outcome? Capacity-specific measures and tests of cognition can provide more objective data about abilities but clinicians may also obtain data from other sources including caregivers and clinicians. At times, an in-home evaluation may be helpful, particularly with questions about capacity for independent living. Clinicians should bear in mind, however, that no single test or piece of evidence can typically be relied upon to make a determination regarding a mental capacity. ◆ Finally, what are the consequences of a capacity determination, positive or negative? Are the deficits observed in an interview permanent or might abilities be restored through medication or improved health? Addressing these questions will help to maintain patients’ dignity and to the extent possible, their agency to act in their own behalf.

Chapter.  10752 words. 

Subjects: Psychiatry ; Geriatric Medicine

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