Helena Hermann

Cognitive Fluctuations as a Challenge for the Assessment of Decision-Making Capacity in Patients With Dementia

Decision-making capacity (DMC) is an indispensable prerequisite for medical treatment choices, including consent to treatment, treatment discontinuation, and refusal of treatment. In patients with dementia, DMC is often affected. A particular challenge in assessing DMC are cognitive fluctuations that may lead to a fluctuation in DMC as well. Cognitive fluctuations are a diagnostic core feature of dementia with Lewy bodies and occur in Parkinson’s and Alzheimer’s diseases. In this article, these challenges are discussed and suggestions for assessing the DMC of patients with dementia with cognitive fluctuations are presented.

Physicians’ personal values in determining medical decision-making capacity: a survey study

Decision-making capacity (DMC) evaluations are complex clinical judgements with important ethical implications for patients’ self-determination. They are achieved not only on descriptive grounds but are inherently normative and, therefore, dependent on the values held by those involved in the DMC evaluation. To date, the issue of whether and how physicians’ personal values relate to DMC evaluation has never been empirically investigated. The present survey study aimed to investigate this question by exploring the relationship between physicians’ value profiles and the use of risk-relative standards in capacity evaluations. The findings indicate that physicians’ personal values are of some significance in this regard. Those physicians with relatively high scores on the value types of achievement, power-resource, face and conformity to interpersonal standards were more likely to apply risk-relative criteria in a range of situations, using more stringent assessment standards when interventions were riskier. By contrast, those physicians who strongly emphasise hedonism, conformity to rules and universalism concern were more likely to apply equal standards regardless of the consequences of a decision. Furthermore, it has been shown that around a quarter of all respondents do not appreciate that their values impact on their DMC evaluations, highlighting a need to better sensitise physicians in this regard. The implications of these findings are discussed, especially in terms of the moral status of the potential and almost unavoidable influence of physicians’ values.

Emotion and Value in the Evaluation of Medical Decision-Making Capacity: A Narrative Review of Arguments

Ever since the traditional criteria for medical decision-making capacity (understanding, appreciation, reasoning, evidencing a choice) were formulated, they have been criticized for not taking sufficient account of emotions or values that seem, according to the critics and in line with clinical experiences, essential to decision-making capacity. The aim of this paper is to provide a nuanced and structured overview of the arguments provided in the literature emphasizing the importance of these factors and arguing for their inclusion in competence evaluations. Moreover, a broader reflection on the findings of the literature is provided. Specific difficulties of formulating and measuring emotional and valuational factors are discussed inviting reflection on the possibility of handling relevant factors in a more flexible, case-specific, and context-specific way rather than adhering to a rigid set of operationalized criteria.

Accounting for Intuition in Decision-Making Capacity: Rethinking the Reasoning Standard?

Abstract: Given the ethical implications of assessments of decision-making capacity, adequate definitions and appropriate assessment criteria are essential, especially with regard to clinical practice in psychiatry. Currently applied standards have been criticized for emphasizing exclusively cognitive abilities. In particular, the present paper questions the adequacy of the current reasoning criterion. Referring to dual-process models of decision making, it is argued that the reasoning standard embraces only one side of the duality that is rational deliberation, and fails to take proper account of intuitive decision making. An outline of intuition’s potency in health care decisions informs the present account of why the current reasoning standard fails to take adequate account of patients’ decision-making preferences and of major deficits in intuitive reasoning. Toward a more comprehensive understanding, a possible reconceptualization of reasoning as the ability to decision-related self-reflection is advanced, and implications for evaluation, challenges, and limitations are discussed.

Evaluating Decision-Making Capacity

The study identified factors that make an evaluation of decision-making capacity (DMC) difficult for clinicians in their daily work. Semistructured interviews were carried out with 24 healthcare professionals from Switzerland and subsequently thematically analyzed. The challenges they faced when evaluating DMC stemmed from three main concerns: patient characteristics that impede DMC evaluation; differing opinions and consequences of DMC evaluation; and familial and legal situations that complicate such evaluations. Physicians must be adequately trained to evaluate DMC as it is closely related to basic ethical principles of respect for patients’ autonomy and beneficence. Extensive training on DMC evaluation and the legal concept of capacity should be part of pre- and postgraduate education.