Decision-Making Capacity
- under the medical model
Dr. Michael A. Valente
• Competency: judicial determination ruling
on a person’s global decision-making ability
• Capacity: clinical observations of a
person’s ability to negotiate tasks and
procedures
– Task or intervention specific
– Expression of values and preferences in isolation from
being able to carry out other higher executive functions
– Does not require legal or psychiatric evaluation
– Consent to Treatment
– Medical Model: problem specific
• Does presence of physical disease impair
judgment?
• Does presence of emotional disorder – psychiatric
disease impair judgment?
– Medical Model
• Mini Mental Status Exam
Quantitative measure of cognitive function
Examination of thought processes based heavily on
language function and visual-spatial relatedness
• Clinical assessment of patient’s judgment and
insight
 Mini Mental Status Exam
Parameter
Score
Orientation: What is the month, day, date, year, season?
Where are you, what floor, city, county, state? (Score 1 point for each item correct.)
10
Registration: State three items (ball, flag, tree). (Score 1 point for each item that the patient registers
without you having to repeat the words. You may repeat the words until the patient is able to
register the words but do not give them credit. You must also tell the patient that he/she should
memorize those words and that you will ask him/her to recall those words later.)
3
Attention: Can you spell the word WORLD forwards, then backwards? Can you subtract 7 from 100,
and keep subtracting 7?
5
Memory: Can you remember those three words I asked you to memorize? (Do not give clues or
multiple choice.)
3
Language:
Naming: Can you name (show) a pen and a watch?
2
Repetition: Can you repeat “No if's, and's, or but's”?
1
Comprehension: Can you take this piece of paper in your right hand, fold it in half, then put it on the
floor?
3
Reading: Read and obey, “CLOSE YOUR EYES.”
1
Writing: Can you write a sentence?
1
Visuospatial: Have patient copy intersecting pentagons
1
TOTAL
Adapted from Folstein MF et al: “Mini-mental state”: A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 12:189, 1975.
30
• Clinical assessment of Judgment and Insight
– The ability to communicate is present
– The ability to understand the proposed treatment and
alternative interventions
– The ability to grasp the consequences of accepting
and of declining the suggested treatment
– The ability to reason
– If present, does mental illness impair judgment