Assessing Capacity in the Complex Patient: Rcat's Unique Evaluation and Consultation Model

Summary

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RCAT is a small specialist assessment team serving a large and varied patient population and demographic area within the CHR. RCAT works as part of a network of other health care providers also involved in capacity assessment and in the care of incapacitated adults. The original vision for a specialized team such as RCAT came from the CHR Competency Assessment Task Group. This multi-disciplinary group of clinicians and administrators believed that an important component of RCAT's role would be to support consistency and excellence among CHR clinicians currently completing capacity assessments. To this end, RCAT was created as a specialized team to develop recommended protocols and tools to enhance inter-rater reliability, consistency in approach, and assessor confidence. Another core initiative for RCAT was to provide formal education and consultation to CHR clinicians regarding capacity assessment protocols and assessment tools. To achieve these goals, a multidisciplinary team was recruited for RCAT, including a neuropsychologist/team leader (0.7 FTE), social worker (1.0 FTE), occupational therapist (1.0 FTE), psychology assistant (0.4 FTE), and a secretary (1.0 FTE). RCAT operates as a freestanding clinic located in central Calgary. The clinic is conveniently located close to most thoroughfares, only a short drive from each of the acute care centres. For the first six months after opening its clinic doors in September of 2005, RCAT staff devoted about 60-70% of their time to providing educational services, with the remainder being consultation and assessment. However, the subsequent six months has involved less emphasis on educational services and more emphasis on assessment services. Currently, RCAT staff spend upward of 80% of their time providing consultation and clinical services, and about 20% providing educational programs. Due to a significant increase in referrals with subsequent increases in wait times, proposals for increased staffing have been submitted in hopes of increasing the FTEs for each of the disciplines currently represented in RCAT.

Obtaining consent is an important part of the RCAT capacity assessment process. RCAT has designed a consent algorithm specifically for use in Alberta, Canada (see Figure 1). The algorithm is based largely upon the work of [Pepper-Smith] et al. (1992). In RCAT's opinion, the ability of a patient to provide informed consent to a formal capacity assessment requires that he/she be able to understand why his/her capacity has come under question, and that he or she have a basic understanding of the nature and purpose of the proposed assessment. Consent should also be distinguished from assent, in which a patient who lacks capacity to consent to the assessment nonetheless cooperates with the assessors and displays a willingness to answer questions about his/her situation (Kothari & Kirschner, 2003). RCAT has special provisions for patients who assent, but are unable to consent to the assessment, as detailed in our consent algorithm. Consider, for example, a recent RCAT assessment of an 82-year-old woman diagnosed with Vascular Dementia and Diabetes Mellitus Type II. At the start of the evaluation, RCAT informed the patient who had initiated the assessment, described the components of the assessment process to her, and reviewed the consent form with her. Despite repeated explanations regarding the nature and purpose of the assessment, however, she was unable to understand why her capacity had been called into question and she was unable to tell RCAT the purpose of the assessment. Nevertheless, the decision was made to proceed with the capacity assessment because she was willing to engage with the examiners and to answer a number of questions regarding her personal care circumstances.

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Assessing Capacity in the Complex Patient: Rcat's Unique Evaluation and Consultation Model

Capacity issues are challenging for everyone involved, due to the multiple legal, ethical, and medical factors involved. The Regional Capacity Assessment Team (RCAT) is currendy the only multidisciplinary team in Canada with the sole function of assessing and addressing capacity issues. It was created in 2005 to address the multiple complexities of capacity evaluations. RCAT serves the Calgary Health Region (CHR), which has a geographic area of 39,260 square kilometres and which serves a population of 1,143,368 (CHR, 2004). The CHR's main source of revenue (87%) is Alberta Health and Wellness (CHR, 2004). RCAT's assessment and consultation mandate includes the provision of services to all adults who have reached the age of majority, with no exclusionary criteria related to diagnosis. RCAT's patients have included adults with dementia, brain injury, psychiatric illness, addiction, and developmental disability. Frequently, there are co-morbid diagnoses, multiple medical conditions, and significant psychosocial stressors present. RCAT assessments are conducted across the CHR care spectrum, which includes acute care, community, and continuing care sites.

Capacity is a socio-legal construct frequently used in the health care domain in relation to decisions about a patient's medical and social care (Weisstub, 1990). Although definitions of capacity vary by jurisdiction, RCAT conceptualizes capacity as the ability to use cognitive processes to understand and identify options, to appreciate the consequences of different options, and to follow through (or direct a surrogate to follow dirough) with chosen options. This conceptualization of capacity, especially as it incorporates understanding and appreciation, reflects current practice and literature in the field (Grisso & Appelbaum, 1998; Office of the Public Guardian and Trustee & Ontario Ministry of the Attorney General, 2000; Weisstub, 1990; Yukon Dep...

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