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Theories and assessment of capacity
Capacity and competency refer to the ability of an individual to make a decision. They are terms that can be used interchangeably although capacity is more commonly used in law (BMA 2004). This is ultimately a legal requirement, and is defined in terms of the law. It is essential that all health care professionals are confident that their patients have made decisions competently and are able assess this. This section considers the factors important in making assessments of capacity and in making decisions when the patient lacks capacity.
To have the capacity to make fully informed decisions a patient should fulfil the following criteria
- The ability to understand in simple language of the purpose of the treatment, its nature and why it has been proposed.
- The ability to understand principal benefits, risks and alternatives of the intervention
- The ability to understand broadly the consequences of not receiving the intervention
- The ability to retain this information to deliberate on it
- The ability to understand the necessary facts and probabilities
- The ability to make voluntary, uncoerced choice
- The ability to make reasoned choice
- The ability to communicate that choice
(GMC 1998; Randall and Downie 2004; BMA 2004)
A patient cannot be found lacking capacity on the basis of knowledge or experience.
In the UK there is a requirement on the healthcare team to assume a patient competent unless proven otherwise (GMC 1998).
However this assessment is specific to the decision faced and when considered alongside the shared approach to decision-making described above it is likely that, when considering sedation at the end of life, such strict criteria cannot always be applied.
Capacity is intrinsically linked to the decision being made (BMA 2004). So, relatively minor decisions need less capacity than more important ones. In considering sedation at the end of life it could be argued that the depth and length of sedation alters the stringency of any tests of capacity applied. A short acting, light sedative may require less stringency than permanent, deeper sedation.
For a patient with capacity, decision making with their involvement is relatively straightforward. In the periods approaching death it is common that patients are unable to maintain full capacity. The indication for sedation is likely to interfere with cognition for example delirium, anxiety, depression or intractable symptoms. The sedation itself will also impair decision-making.
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