Patients on acute medical wards can present with a variety of acute or chronic medical, cognitive and psychiatric/psychological co-morbidities that can affect their capacity to make important treatment and discharge decisions. Determinations about capacity are required relatively quickly, but research has demonstrated the challenges and limitations associated with informal clinical impressions of capacity (Etchells et al., 1997) or relying on screening measures of cognition (Fassassi et al., 2009). Clinical neuropsychologists are therefore uniquely placed to be able to synthesise the complex issues, utilise appropriate clinical tools, provide an informed opinion regarding a patient’s capacity and propose recommendations based on the assessment.
Typical referral scenarios
Although referral questions to neuropsychology are varied, there are generally two common themes. The first of these is conflict between the wishes of the patient and the recommendations of the treating team, which may be related to medical decision making (e.g., ability to provide consent to a procedure or to withholding treatment) or a patient’s ‘lifestyle choices’ (e.g., in the context of a proposed discharge destination). The second theme involves a suspicion that the patient’s capacity is impaired by the presence of a cognitive disability secondary to an underlying intellectual, organic or psychiatric illness.
Jane is a 52-year-old woman admitted following a motor vehicle accident. The treating team recommended insertion of a metal pin to stabilise a fracture in her femur, but Jane refused to consent to surgery, was unable to walk and was becoming increasingly agitated by the team’s ‘intrusiveness’. Cognitive screening and psychiatric assessment did not reveal any evident disorder. However, neuropsychological assessment revealed a cognitive disability in the context of a developmental cognitive disorder and a variety of other cerebrovascular changes. On clinical interview, it was clear that this cognitive disability impaired Jane’s capacity to consent to treatment as she had a very limited understanding of the nature of the procedure and was confused about its possible risks and benefits.
Phil is a 58-year-old homeless man with a long history of alcohol abuse, who had presented to the emergency department 15 times in the last eight weeks in the context of alcohol intoxication, falls and other associated complications. The treating team had recommended discharge to a residential care facility to minimise Phil’s alcohol consumption, however he was unwilling to accept this. Neuropsychological assessment identified a cognitive disability secondary to long-term alcohol abuse, and the clinical interview highlighted an impaired ability to make informed and reasoned lifestyle choices. The clinical interview also identified some of the triggers associated with his alcohol abuse (including social isolation, depression and anxiety).
In both of these instances, the role of the neuropsychologist is to both inform the treating team of how any cognitive disability impacts the patients’ capacity, but more importantly, to provide advice about management options. In Jane’s example, the assessment information enabled a shift towards a more collaborative treatment plan providing Jane with more accessible treatment information and engaging her family in decision making. In Phil’s situation, the identification of psychological triggers provided a different perspective to address the perceived conflict, and enabled a multi-disciplinary team approach to link him in with community services.
Practice and ethical considerations
Assessments of capacity on an acute medical ward are frequently performed under time pressure, in sub-optimal assessment environments (e.g., with background noise and interruptions) and in the context of acute medical illness. All of these factors must be taken into account given their potential to adversely impact upon the patient’s performance on standardised psychometric testing.
The pace of an acute medical ward also poses a unique challenge in the assessment of capacity. Treating teams frequently request opinions extremely quickly, often within minutes of seeing the patient. Given the situation is often complex and may have significant consequences, neuropsychologists must balance the need for a ‘quick decision’ with ensuring a thorough examination of the situation that takes into account the limitations of the test environment.
Considerations for test selection and interpretation
Neuropsychologists will use a variety of clinical assessment tools to establish whether a cognitive disability is present, with tests selected to assess hypotheses about the patients underlying cognitive strengths and weaknesses. The limitations of the assessment environment highlight the importance of the clinical interview when forming an opinion about a patient’s capacity. As in the case of both Jane and Phil, a substantial amount of information can be gleaned from asking about their impressions of the current situation and their understanding of the decision at hand. Neuropsychologists on acute medical wards are well placed to take an inquisitive position with patients, as they are seldom involved in the initial treatment. The capacity determination seldom occurs in isolation and will likely involve discussions with the patient’s family and the treating team, and may also involve consultation with psychiatry to determine whether a psychiatric illness impacts capacity.