A prospective observational study of decisional capacity determinations in an academic medical center

Debra R Kahn, James A. Bourgeois, Sally C. Klein, Ana-Maria Iosif

Research output: Contribution to journalArticle

16 Citations (Scopus)

Abstract

Objective: The main goals of this observational study were to clarify and categorize decisional capacity assessments performed by a psychosomatic medicine (PSM) consult service at an academic medical center. Areas of investigation included types of decisional capacity requests, the relationship between Folstein Mini-Mental State Exam (MMSE) and PSM decisional capacity determination, psychiatric diagnoses of patients, and the agreement between primary clinician capacity assessment and that of the PSM clinician. Method: This was a prospective study of 100 consecutive decisional capacity consultations. Twelve requests were for second consultations for patients previously seen, for a net of 88 patients. Results: In 77 cases, patients lacked decisional capacity. Assessments for capacity to leave against medical advice (AMA), capacity to accept medical/surgical procedures, capacity to refuse medical/surgical procedures, and capacity to participate in discharge planning were nearly equally frequent. An MMSE cutoff score of < 21 was found to be 100% specific and 69% sensitive for identifying the patients without capacity, while a cutoff of < 24 was found to be 83% sensitive and 90% specific for identifying patients without capacity. The primary psychiatric diagnosis was a cognitive disorder in 52 cases. In 38 of the 39 cases where the primary team believed the patient lacked capacity, the PSM service agreed. In only two of the seven cases where primary teams believed patients had capacity did the PSM team agree. Conclusions: The MMSE was a useful predictor of capacity determination by PSM personnel, but using MMSE alone results in a number of erroneous determinations. Cognitive disorders were the most common primary psychiatric diagnoses in decisional capacity cases. Primary teams tended to be more accurate when they found patients to lack capacity.

Original languageEnglish (US)
Pages (from-to)405-415
Number of pages11
JournalInternational Journal of Psychiatry in Medicine
Volume39
Issue number4
DOIs
StatePublished - Jan 1 2009

Fingerprint

Psychosomatic Medicine
Observational Studies
Prospective Studies
Mental Disorders
Referral and Consultation
State Medicine
Patient Discharge

Keywords

  • Cognitive disorders
  • Decisional capacity
  • Mini-Mental State Examination

ASJC Scopus subject areas

  • Psychiatry and Mental health

Cite this

A prospective observational study of decisional capacity determinations in an academic medical center. / Kahn, Debra R; Bourgeois, James A.; Klein, Sally C.; Iosif, Ana-Maria.

In: International Journal of Psychiatry in Medicine, Vol. 39, No. 4, 01.01.2009, p. 405-415.

Research output: Contribution to journalArticle

@article{d760e6916c354b9cbf8cbf241a0afb1b,
title = "A prospective observational study of decisional capacity determinations in an academic medical center",
abstract = "Objective: The main goals of this observational study were to clarify and categorize decisional capacity assessments performed by a psychosomatic medicine (PSM) consult service at an academic medical center. Areas of investigation included types of decisional capacity requests, the relationship between Folstein Mini-Mental State Exam (MMSE) and PSM decisional capacity determination, psychiatric diagnoses of patients, and the agreement between primary clinician capacity assessment and that of the PSM clinician. Method: This was a prospective study of 100 consecutive decisional capacity consultations. Twelve requests were for second consultations for patients previously seen, for a net of 88 patients. Results: In 77 cases, patients lacked decisional capacity. Assessments for capacity to leave against medical advice (AMA), capacity to accept medical/surgical procedures, capacity to refuse medical/surgical procedures, and capacity to participate in discharge planning were nearly equally frequent. An MMSE cutoff score of < 21 was found to be 100{\%} specific and 69{\%} sensitive for identifying the patients without capacity, while a cutoff of < 24 was found to be 83{\%} sensitive and 90{\%} specific for identifying patients without capacity. The primary psychiatric diagnosis was a cognitive disorder in 52 cases. In 38 of the 39 cases where the primary team believed the patient lacked capacity, the PSM service agreed. In only two of the seven cases where primary teams believed patients had capacity did the PSM team agree. Conclusions: The MMSE was a useful predictor of capacity determination by PSM personnel, but using MMSE alone results in a number of erroneous determinations. Cognitive disorders were the most common primary psychiatric diagnoses in decisional capacity cases. Primary teams tended to be more accurate when they found patients to lack capacity.",
keywords = "Cognitive disorders, Decisional capacity, Mini-Mental State Examination",
author = "Kahn, {Debra R} and Bourgeois, {James A.} and Klein, {Sally C.} and Ana-Maria Iosif",
year = "2009",
month = "1",
day = "1",
doi = "10.2190/PM.39.4.e",
language = "English (US)",
volume = "39",
pages = "405--415",
journal = "International Journal of Psychiatry in Medicine",
issn = "0091-2174",
publisher = "Baywood Publishing Co. Inc.",
number = "4",

}

TY - JOUR

T1 - A prospective observational study of decisional capacity determinations in an academic medical center

AU - Kahn, Debra R

AU - Bourgeois, James A.

AU - Klein, Sally C.

AU - Iosif, Ana-Maria

PY - 2009/1/1

Y1 - 2009/1/1

N2 - Objective: The main goals of this observational study were to clarify and categorize decisional capacity assessments performed by a psychosomatic medicine (PSM) consult service at an academic medical center. Areas of investigation included types of decisional capacity requests, the relationship between Folstein Mini-Mental State Exam (MMSE) and PSM decisional capacity determination, psychiatric diagnoses of patients, and the agreement between primary clinician capacity assessment and that of the PSM clinician. Method: This was a prospective study of 100 consecutive decisional capacity consultations. Twelve requests were for second consultations for patients previously seen, for a net of 88 patients. Results: In 77 cases, patients lacked decisional capacity. Assessments for capacity to leave against medical advice (AMA), capacity to accept medical/surgical procedures, capacity to refuse medical/surgical procedures, and capacity to participate in discharge planning were nearly equally frequent. An MMSE cutoff score of < 21 was found to be 100% specific and 69% sensitive for identifying the patients without capacity, while a cutoff of < 24 was found to be 83% sensitive and 90% specific for identifying patients without capacity. The primary psychiatric diagnosis was a cognitive disorder in 52 cases. In 38 of the 39 cases where the primary team believed the patient lacked capacity, the PSM service agreed. In only two of the seven cases where primary teams believed patients had capacity did the PSM team agree. Conclusions: The MMSE was a useful predictor of capacity determination by PSM personnel, but using MMSE alone results in a number of erroneous determinations. Cognitive disorders were the most common primary psychiatric diagnoses in decisional capacity cases. Primary teams tended to be more accurate when they found patients to lack capacity.

AB - Objective: The main goals of this observational study were to clarify and categorize decisional capacity assessments performed by a psychosomatic medicine (PSM) consult service at an academic medical center. Areas of investigation included types of decisional capacity requests, the relationship between Folstein Mini-Mental State Exam (MMSE) and PSM decisional capacity determination, psychiatric diagnoses of patients, and the agreement between primary clinician capacity assessment and that of the PSM clinician. Method: This was a prospective study of 100 consecutive decisional capacity consultations. Twelve requests were for second consultations for patients previously seen, for a net of 88 patients. Results: In 77 cases, patients lacked decisional capacity. Assessments for capacity to leave against medical advice (AMA), capacity to accept medical/surgical procedures, capacity to refuse medical/surgical procedures, and capacity to participate in discharge planning were nearly equally frequent. An MMSE cutoff score of < 21 was found to be 100% specific and 69% sensitive for identifying the patients without capacity, while a cutoff of < 24 was found to be 83% sensitive and 90% specific for identifying patients without capacity. The primary psychiatric diagnosis was a cognitive disorder in 52 cases. In 38 of the 39 cases where the primary team believed the patient lacked capacity, the PSM service agreed. In only two of the seven cases where primary teams believed patients had capacity did the PSM team agree. Conclusions: The MMSE was a useful predictor of capacity determination by PSM personnel, but using MMSE alone results in a number of erroneous determinations. Cognitive disorders were the most common primary psychiatric diagnoses in decisional capacity cases. Primary teams tended to be more accurate when they found patients to lack capacity.

KW - Cognitive disorders

KW - Decisional capacity

KW - Mini-Mental State Examination

UR - http://www.scopus.com/inward/record.url?scp=76949098740&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=76949098740&partnerID=8YFLogxK

U2 - 10.2190/PM.39.4.e

DO - 10.2190/PM.39.4.e

M3 - Article

C2 - 20391861

AN - SCOPUS:76949098740

VL - 39

SP - 405

EP - 415

JO - International Journal of Psychiatry in Medicine

JF - International Journal of Psychiatry in Medicine

SN - 0091-2174

IS - 4

ER -