Aging and Competency Research Paper

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Abstract

Many people use the concept of competency in clinical settings, although there continues to be confusion about what it means, when it is relevant, and how it should be assessed. All adults are presumed to be legally competent unless otherwise determined in a court of law. An adult’s competency may be questioned when a family member or other interested party files a petition for guardianship of that individual. If incompetency  is found in a court hearing, a guardian or conservator may be appointed. In most states, a guardian is responsible for decisions regarding  the  care  of the  individual’s  ‘‘person’’  (e.g., day-to-day issues of care, residence, and activities), whereas a conservator is responsible for decisions regarding the care of the ‘‘estate’’ (i.e., management  of assets).

Outline

  1. Clinical Versus Legal Competency
  2. Competency Versus Capacity
  3. Legal Frameworks for Aging and Competency
  4. Decision-Making Abilities in Competency
  5. Clinical Evaluations of Capacities
  6. Categories of Capacities

1. Clinical Versus Legal Competency

Although clinicians may question a patient’s competency status and may request other clinicians to evaluate the patient’s competency, a clinical finding of incompetency should not be confused with a judicial determination  of incompetency.  The  clinical  use  of the  term  ‘‘competency’’ refers to a clinical opinion regarding the patient’s decisional capacities. Such an opinion  may be used to activate a durable power of attorney or health care proxy if one exists. However, clinical statements  about capacities should not be equated with court-determined findings of incompetency.

 2. Competency Versus Capacity

Increasingly, the term ‘‘capacity’’ is preferred to competency. The use of capacity recognizes the possibility of individual strengths and weaknesses or functional capacities rather than the all-or-none notion of incompetency.

3. Legal Frameworks For Aging And Competency

In the United States, most statutory definitions of incapacity to care for one’s person  or estate include  four parts,  as  shown  in  Fig.  1.  This  four-part  definition means that a diagnosis is a necessary, but not a sufficient, component  of incompetency.  Rather, information must be  provided  as to  how  the  disease  affects attention, memory, information  processing,  and so forth as well as, in  turn,  how  these  symptoms  affect the  person’s ability to do certain things or make specific decisions. The ability level should be considered within the context of the environmental  demands and resources as well as specific situational risks and benefits. For example, the threshold for the capacity to reasonably manage a small amount of day-to-day cash spending would be different from  the  capacity  to  manage  a complex  portfolio  of investments,  and  the  abilities needed  for the capacity to consent to a relatively harmless medical intervention (e.g., a flu shot) would be much lower than those needed to consent  to a more risky medical intervention  (e.g., heart bypass surgery).

Aging and Competency Research Paper f1  FIGURE 1    Four components of most U.S. statutory definitions of competency.

4. Decision-Making Abilities In Competency

Much U.S. case law about  competency  to consent  to treatment  refers to four decision-making  abilities,  as shown  in Table I. Case law typically refers to these abilities  individually  as independent   legal standards. Together, they form a useful framework for evaluating decisional processes.

5. Clinical Evaluations Of Capacities

 5.1.  Competency and Older  Adults

Although the large majority of guardianships  concern elderly individuals with psychiatric or neurological diagnoses,  it is clear  that  advancing  age or  physical frailty themselves  are  not  grounds  for guardianship. Competency  questions  are increasing for older adults due to the age-associated increase in prevalence of dementia  that can affect competency  during  the later stages of the disease.

Aging and Competency Research Paper t1TABLE  I Four Decision-Making  Abilities Important for Legally Competency

5.2.  Competency Assessment

In the  past,  most  clinical  evaluations  of competency relied on a physician’s interview or knowledge of the patient.  However, such approaches  can be unreliable. A more  objective evaluation  of competency,  particularly  important  in  more  complicated  cases, involves three parts, as shown in Table II.

5.3.  Ethical Issues

5.3.1. Consequences of Guardianship

Many  adults   who   receive  guardianship   experience benefit  from  the  arrangement.  In  the  best  case,  the individual receives needed care, supervision, and advocacy in accordance with his or her wishes. In the worst case, guardians may take advantage of the individual’s assets. In either case, removal of competency results in the loss of the right to make choices about residency, health care, medication, relationships, marriage, contracts,  voting,  driving,  use  of leisure  time,  and  how one’s  own  money  is spent.  Such losses in  autonomy may affect the individual’s emotional well-being. These potential rights deprivations and personal consequences of incompetency underscore the special care that should be taken in competency assessments and the extra attention that should be devoted to ethical concerns.

Aging and Competency Research Paper t2TABLE II Components of Competency Assessment

5.3.2. Informed Consent

An individual who is the subject of a competency evaluation needs to be informed of the nature of the evaluation and the potential consequences. Obtaining informed consent for the evaluation of competency from a person whose decision-making capacity is in question requires special care. Clinicians should fully disclose information about the evaluation and its risks and benefits in clear and direct language and then should assess the individual’s ability to understand,  appreciate, and reason through the information and options.

5.3.3. Individual and  Cultural  Differences

Persons from different ethnic or age backgrounds  may have different cultural and cohort preferences for medical care, finances, living situations, relationships, and so forth. Evaluators must be sensitive so that individual and cultural differences are not misconstrued as incompetent decisional processes. This also applies to the use of standardized  tests because some do not have adequate normative data concerning cultural, cohort, and educational influences on test performance, especially in older populations.  Test instruments  should  be given in the primary language of the person being assessed.

6. Categories Of Capacities

6.1.  Financial Management

As shown in Table III, one important category of competency is the capacity to manage finances, including managing assets and how one spends money, managing debts  and  how one  pays bills, and  managing  specific issues of contracts,  disposition  of property,  and wills. Such financial capacities may involve knowledge of facts (e.g., where one’s bank account is), financial skills (e.g., counting change), and financial judgment (e.g., avoiding fraud). As indicated in the table, services can sometimes provide alternatives to guardianship.

Aging and Competency Research Paper t3TABLE  III Categories of Competency

6.2.  Health Care

Another category of competency focuses on health care, especially the capacity to consent to treatment.  Health care capacities may also cover managing day-to-day health such as nutrition,  wound care, and medications.

6.3.  Independent Living

A  third   and   more  broad   category  of  competency concerns  the capacity to live independently.  Tasks in this category include household  cleaning and maintenance,  laundry,  meal shopping  and  preparation,  and communication  (telephone  and  mail).  Senior service agencies have a wealth of services to assist vulnerable adults  in living independently,  including  homemaker services  to  clean,  do  laundry,   and  prepare   meals; ‘‘chore’’  services to  tackle  larger  tasks  such  as lawn care and snow removal; and meal delivery programs. Communication  aids, including large-button telephones,  assistive  devices,  and  animals  for  the  deaf and  hard  of hearing,  may also promote  independent living.  Medical  alert  systems  can  be  installed   for seniors to enact in the event of a disabling emergency.

 6.4.  Transportation

A more narrow category of functional abilities concerns transportation and the capacity to drive a motor vehicle. This question  may arise outside  of other  competency concerns when an adult with a disabling psychiatric or neurological  condition  has  a  series  of motor  vehicle accidents.

References:

  1. Department of Veterans Affairs. (1997).  Clinical assessment for competency determination: A practice guideline for psychologists. Milwaukee,  WI:  National   Center   for  Cost Containment.
  2. Edelstein, B. (2000). Challenges in the assessment of decision-making capacity. Journal of Aging Studies, 14, 423–437. Earnst,   S.,  Marson,  D.  C.,  &  Harrell,  L.  E.  (2000).
  3. Cognitive models of physicians’ legal standard and person judgments of competency  in  patients  with  Alzheimer’s disease.  Journal  of  the  American Geriatric  Society, 48, 919–927.
  4. Grisso, T. (2002). Evaluating Competencies (2nd  ).  New York: Plenum.
  5. Grisso, ,  &  Appelbaum,  P.  S. (1995).  The  MacArthur Treatment  Competence  Study III: Abilities of patients  to consent  to psychiatric  and  medical treatments.  Law and Human Behavior, 19, 149–174.
  6. Marson, D. C., Ingram, K. K., Cody, H. A., & Harrell, L. E. (1995). Assessing the competency of patients with Alzheimer’s disease under different legal standards. Archives of Neurology, 52, 949–954.
  7. Marson, D. C., McInturff, B., Hawkins, L., Bartolucci, A., & Harrell, L. E. (1997). Consistency of physician judgments of capacity to consent in mild Alzheimer’s disease. Journal of the American Geriatric Society, 45, 453–457.
  8. Moye, J. (1999). Assessment of competency  and  decision making  In P. Lichtenberg  (Ed.),  Handbook of geriatric  assessment  (pp.   488–528).   New  York:  John Wiley.
  9. Moye, J., & Karel, M. J. (1999). Evaluating decisional capacities in older adults: Results of two clinical studies. Advances in Medical Psychotherapy, 10, 71–84.
  10. Park, C., Morrell, R. W., &  Shifren, K. (Eds.).  (1999). Processing of medical information in aging patients: Cognition and  human  factors  perspectives Mahwah,  NJ: Lawrence Erlbaum.
  11. Seckler,   B., Meier,  D.  E.,  Mulvihill,  M.,  &  Cammer Paris, B. E. (1991).  Substituted  judgment:  How accurate are proxy predictions?.  Annals of Internal Medicine, 115, 92–98.
  12. Smyer, M., Schaie, K. W., & Kapp, M. B. (Eds.). (1996). Older adults’ decision making and the law New York: Springer. Zimny, G. H., & Grossberg, G. T. (1998). Guardianship of the elderly. New York: Springer.

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