Unit
- Capacity vs. Competence: Capacity refers to a person's ability to make a specific decision at a given time, while competence is a legal determination made by a court. Clinicians assess capacity; courts decide competence. Understanding this distinction prevents overreach by practitioners.
- Decision-Specific Nature: Capacity is not global; a person may have capacity for some decisions (e.g., choice of meal) but not others (e.g., complex financial planning). Assessments must be tailored to the specific decision in question.
- Functional Approach: Modern capacity assessment focuses on the person's ability to understand, appreciate, reason, and communicate a decision, not on diagnosis or age alone. Functional evaluation respects individual autonomy.
- Presumption of Capacity: Legal and ethical frameworks presume every adult has capacity unless proven otherwise. This presumption places the burden of proof on the assessor and protects individual rights.
- Fluctuation Over Time: Capacity can change due to medical conditions, medications, fatigue, or stress. Assessments should consider timing and may need repetition for accurate determination.
- Role of Values and Beliefs: A person's decisions may deviate from typical norms but still reflect their values. Capacity assessment must distinguish between unconventional choices and inability to understand consequences.
- Thresholds for Capacity: Different decisions require different levels of ability. Higher-stakes decisions (e.g., life-sustaining treatment) demand a higher standard of understanding than routine choices.
- Interdisciplinary Input: Comprehensive assessments often involve input from physicians, psychologists, social workers, and family members to gather a full picture of the individual's functioning and context.
- Four Abilities Model: The standard framework for functional capacity assessment includes understanding relevant information, appreciating its significance for one's own situation, reasoning logically with the information, and expressing a choice. Each ability must be evaluated separately to determine overall capacity for a given decision.
- Contextual Influences: Environmental factors such as setting, time of day, presence of familiar people, and communication methods can significantly affect a person's capacity performance. Assessments should be conducted in optimal conditions and, when possible, in the individual's usual environment to obtain a valid picture.
- Documentation Standards: Capacity assessment findings must be documented clearly, including the specific decision assessed, the criteria used, the individual's performance on each ability, and the reasoning for the determination. Adequate documentation supports clinical decisions and protects against legal challenges.
Scope of Practice
Role: Capacity Assessor in Clinical Setting
Within scope:
- Conducting capacity evaluations for specific decisions using validated tools and clinical judgment.
- Documenting findings and rationale in the medical record.
- Communicating results to the healthcare team and, with consent, to family or legal representatives.
- Providing recommendations for support strategies when capacity is impaired.
- Reassessing capacity when clinical status changes.
Outside scope:
- Making legal determinations of incompetence; that is a judicial function.
- Forcing treatment or care against a person's will based solely on capacity findings; legal authority is needed.
- Assessing capacity without proper training in relevant tools and ethical guidelines.
- Disclosing capacity results without patient consent except as required by law.
- Issuing opinions on capacity for decisions outside the assessor's expertise (e.g., legal capacity for contracts without legal training).
Quick Revision
- Capacity is decision-specific and time-specific; competence is a legal adjudication.
- Presume capacity; use a functional approach focusing on understanding, appreciation, reasoning, and communication.
- Capacity can fluctuate; reassess as needed. Document all findings thoroughly.
- Collaborate with interdisciplinary team members for a holistic evaluation.