Assessing Decision-Making Capacity in Patients with Communication Impairments
A Case Study
Published online by Cambridge University Press: 16 September 2016
The ethical principle of autonomy requires physicians to respect patient autonomy when present, and to protect the patient who lacks autonomy. Fulfilling this ethical obligation when a patient has a communication impairment presents considerable challenges. Standard methods for evaluating decision-making capacity require a semistructured interview. Some patients with communication impairments are unable to engage in a semistructured interview and are at risk of the wrongful loss of autonomy. In this article, we present a general strategy for assessing decision-making capacity in patients with communication impairments. We derive this strategy by reflecting on a particular case. The strategy involves three steps: (1) determining the reliability of communication, (2) widening the bandwidth of communication, and (3) using compensatory measures of decision-making capacity. We argue that this strategy may be useful for assessing decision-making capacity and preserving autonomy in some patients with communication impairments.
- Cambridge Quarterly of Healthcare Ethics , Volume 25 , Special Issue 4: Clinical Neuroethics , October 2016 , pp. 691 - 699
- Copyright © Cambridge University Press 2016
2. Faden, RR, Beauchamp, TL, King, NM. A History and Theory of Informed Consent. New York: Oxford University Press; 1986.Google Scholar
5. Americans with Disabilities Act of 1990, Pub. L. No. 101-336, 104 Stat. 328 (1990).
6. UN General Assembly. Convention on the Rights of Person with Disabilities: Resolution Adopted by the General Assembly. A/RES/61/106; 2007 Jan 24.
7. Grisso, T, Appelbaum, PS. Assessing Competence to Consent to Treatment: A Guide for Physicians and Other Health Professionals. New York: Oxford University Press; 1998.Google Scholar
8. Carling-Rowland EA. Adaptation of the capacity evaluation process to make admission decisions: Increasing access for people with aphasia and other communication barriers [dissertation]. Toronto, ON: University of Toronto; 2011.
9. See note 8, Carling-Rowland 2011.
13. Diener BL, Bischof-Rosario JA. Determining decision-making capacity in individuals with severe communication impairments after stroke: The role of augmentative-alternative communication (AAC). Topics in Stroke Rehabilitation 2004 Jan 1;11(1):84–8.
14. Dunn LB, Jeste DV. Enhancing informed consent for research and treatment. Neuropsychopharmacology 2001 June 1;24(6):595–607.
17. See note 16, Dreer et al. 2008.
18. Triebel KL, Novack TA, Kennedy R, Martin RC, Dreer LE, Raman R, et al. Neurocognitive models of medical decision-making capacity in traumatic brain injury across injury severity. Journal of Head Trauma Rehabilitation 2016 May–June ;31(3):E49–59.
19. Taub HA, Baker MT. The effect of repeated testing upon comprehension of informed consent materials by elderly volunteers. Experimental Aging Research 1983 Sept 1;9(3):135–8.
20. Taub HA, Kline GE, Baker MT. The elderly and informed consent: Effects of vocabulary level and corrected feedback. Experimental Aging Research 1981 June 1;7(2):137–46.
21. Gerstenecker A, Meneses K, Duff K, Fiveash JB, Marson DC, Triebel KL. Cognitive predictors of understanding treatment decisions in patients with newly diagnosed brain metastasis. Cancer 2015 June 15;121(12):2013–9.
22. Stern, RA, White, T. Neuropsychological Assessment Battery. Lutz, FL: Psychological Assessment Resources; 2003.Google Scholar
23. Dunn L, Dunn D. Peabody Picture Vocabulary Test: Examiner’s Manual. 4th ed. San Antonio, TX: Pearson Assessments; 2007.
24. Heaton RK, Chelune GJ, Talley JL, Kay GG, Curtis G. Wisconsin Card Sorting Test (WCST) Manual. Revised and expanded ed. Odessa, FL: Psychological Assessment Resources; 1993.
25. See note 22, Stern, White 2003.
26. Delis D, Kaplan E, Kramer J. Delis-Kaplan Executive Function System. The Psychological Corporation. San Antonio, TX: Harcourt Brace; 2001.
27. See note 16, Dreer et al. 2008.
28. See note 7, Grisso, Appelbaum 1998.
29. Buchanan, AE, Brock, DW. Deciding for Others: The Ethics of Surrogate Decision Making. Cambridge: Cambridge University Press; 1989.Google Scholar
30. See note 29, Buchanan, Brock 1989.
32. Peterson A, Naci L, Weijer C, Cruse D, Fernández-Espejo D, Graham M, et al. Assessing decision-making capacity in the behaviorally nonresponsive patient with residual covert awareness. American Journal of Bioethics Neuroscience 2013 Oct 1;4(4):3–14.