Decision-making capacity evaluations: the role of neuropsychological assessment from a multidisciplinary perspective

Abstract

Decision-making capacity (DMC) in aging adults has become increasingly salient as the number of older adults, life expectancy, and the amount of wealth to be transferred from older generations have all increased. The accurate and reliable determination of older adults’ DMC is a particularly important topic given its implication in legal, financial, and health decisions. Based upon the four-ability DMC model promulgated by Appelbaum and Grisso in the 1980’s, a number of MacArthur Competence Assessment Tools have been developed and widely utilized. However, these tools do not include cognitive testing or other sources of objective data and have limited validity in a medico-legal setting, necessitating additional options for the evaluation of DMC. This is significant from the perspective of the patient because they have a vested interest in accurate and objective assessment of their DMC across domains.Given the disparities in the assessment of DMC, the authors propose, through this debate article, that the evaluation of DMC in the aging adult population utilize a combination of traditional interview and domain specific instruments and neuropsychological testing. To achieve a consensus on the issue, medical experts in a number of fields related to capacity evaluation, including psychiatry, neurology, neuropsychology, and general medicine were consulted and recruited as authors. Experts in Swiss law and ethics were also consulted and provided input.A tendency to focus on a single capacity, and in particular, the ability to consent to medical treatment, arose in the literature. Similarly, there are many instruments purporting to evaluate a single capacity (e.g., consenting to medical treatment, managing finances), while other areas important to the evaluation of DMC received little attention (e.g., activities of daily living, the ability to live independently, to marry, to resist undue influence, and to make a will or advanced care directive). Medical and legal experts in the multidisciplinary group agreed that there is a clear need for more consistency across evaluation of DMC domains and that a combined approach of traditional methods and neuropsychological testing provides a more thorough evaluation and better serves the patient.

Decisional capacity determination and serious mental illness in oncology: Implications for equitable and beneficent care

“…28 Historically, the use of cognitive testing alone to determine DMC was considered adequate. 29 The practice of DMC determination advanced significantly with the 'relational' approach that matches patient factors to the situational or clinical complexity for patient engagement-it is practical, protects patient autonomy, and allows for selfdetermination in many patients. 30 But, a cross-sectional approach does not adequately capture patient perspectives or proclivities and overly simplifies patient decision making in the name of patientcentered care.…”

Curatorship applications: The role of neuropsychology

“…[8,10,11] While it is an increasingly routine request made of psychologists, [7,9,12] a high level of ethical awareness is encouraged among all mental health professionals. [13,14] Ethical awareness in these cases is important, as the role of neuropsychology in this process may be inconsistent [13,14] and is often scrutinised by practitioners, international working groups, and academics in the field. [12][13][14][15] Similarly, the efficacy of some neuropsychological tests as an indicator of functioning has been questioned.…”

“…[13,14] Ethical awareness in these cases is important, as the role of neuropsychology in this process may be inconsistent [13,14] and is often scrutinised by practitioners, international working groups, and academics in the field. [12][13][14][15] Similarly, the efficacy of some neuropsychological tests as an indicator of functioning has been questioned. [1,16,17] Several core ethical practices outlined by SA law [18][19][20][21][22][23] as well as the Health Professions Council of South Africa (HPCSA) [24,25] are relevant to the curatorship process.…”

“…These include the realities of training and testing in SA, [42,43] the standards and nature of report writing more generally, [29] and the controversy regarding the efficaciousness of neuropsychological tests as measures of day-to-day functioning. [14,29] Revisiting the unstipulated parameters of practitioner 'competency' , Watts and Shuttleworth-Edwards [43] state that neuropsychological practice in South Africa is known to have variances in training, with the level of baseline competency dependent on the basic training. They describe university instruction as 'ad hoc' , with a small number of experienced supervisors available.…”

“…[29] More generally, it is recommended that the process of capacity assessment should be multidisciplinary. [14] The limitations of neuropsychological tests as predictors of functionality [13,45] sometimes remain unacknowledged, yet the tests are still considered to support arguments for curatorship. [7] A holistic approach should be taken when evaluating competency.…”