Memory & Mood

Mental Competency for Medical Decisions – What You Should Know

Being able to understand medical information and make rational, informed decisions about our medical care is an important part of our identity as autonomous, independent individuals. But for many older adults, cognitive impairment related to Alzheimer’s disease (AD), dementia, stroke, or other causes may interfere with the ability to understand and make important medical decisions.

“Geriatric psychiatrists often assist other physicians and family members in determining older adults’ ability to make medical decisions,” explains UAB geriatric psychiatrist Terri Steele, MD. “Because competency is a legal determination that must be made by a judge, the term ‘capacity’ to give informed consent regarding medical procedures is a more accurate term. Specifically, this involves assessing whether an older adult is capable of understanding medical information and making informed decisions related to treatments and end-of-life care.”

How Competency is Determined

Dr. Steele says that, in a hospital setting, there is often a need to determine whether an older adult can understand treatment options, give consent for a procedure, or express preferences regarding end-of-life care.

“In these situations, I talk to the patient about the issue – whether it’s a certain treatment, procedure, or end-of-life care,” says Dr. Steele. “After presenting the information, I ask the patient to repeat it back to me. Later, I ask the patient to repeat it to me again. If he or she is lucid and able to grasp the information we’ve discussed, I feel comfortable making a determination that the patient has the capacity to give informed consent.”

Dr. Steele stresses that in patients with mild dementia, the determination can be more complicated. “Often, many of these patients may have difficulty remembering what day or year it is,” she explains. “However, they may be perfectly able to express their preferences regarding end-of-life care or to give informed consent about a medical procedure.”

She says in cases where the patient is unable to understand or remember the information presented, it’s important to involve family members who can advise the treating physician about the patient’s wishes. “When this isn’t possible, we bring in a second physician to confirm that a patient doesn’t have the capacity to make his or her own medical decisions,” says Dr. Steele. “At that point, both physicians confer about the best treatment for the patient.”

Importance of Advance Directives (Living Wills)

Dr. Steele points out that having an advance directive — or living will — eliminates the need for physicians to determine an older adult’s competency regarding end-of-life decisions. This legal document expresses your values and wishes regarding extraordinary measures that can be used to sustain life, such as feeding tubes, ventilators, and other technologies.

“It’s important for everyone to have an advanced directive,” says Dr. Steele. “If you become cognitively impaired or unconscious, this document will serve to communicate the medical treatments and procedures you want — or don’t want — during end-of-life care.” She adds that it’s equally important to name a durable power of attorney for medical decisions in the event that you become unable to make these decisions for yourself. “This individual will have responsibility for making decisions regarding your care and should be someone you completely trust. You can work closely with your physician and an elder law specialist in creating a living will and durable power of attorney that expresses your values and wishes.”