Evaluación Cuantitativa (FAIR)

serious health decisions, yet little normative information about the decision-making abilities of older adults exists. The growth of the elderly population in the USA and the widespread availability of life-sustaining technology under-score the need for proper assessment of medical decision-making ability.

Assessment schemes depend on definitions of competence and the standards used to oper-ationalize the concept. Several assessment schemes are examined below, and some of their problems are explored. Table 2 presents an overview of this discussion. As the table demonstrates, all systems reviewed here include at least some aspect of ªUnderstanding.º The systems differ in their attention to the other conceptual elements. Mental status is arguably an implied component of most, especially those which address memory and language elements explicitly. The rationality and appreciation elements are discussed for each example.

7.06.5.1 Assessment of Competence to Consent to Treatment

An example of an early competence assess-ment scheme is that of Stanley et al., (1984).

Comprehension figures prominently, as does

Table 2 Conceptual elements addressed in the empirical assessment of competence (organized by type of competence).

Conceptual Element

Mental status Understanding Memory Language Reasoning Rationality Appreciation Type of competence

Consent to treatment

Stanley et al., 1984 X X X

Wang and Ennis, 1986 X X X

Draper and Dawson, 1990 X X X

Fitten and Waite, 1990 X X

Freedman et al., 1991 X X X X X

Janofsky et al., 1992 X

Appelbaum and Grisso, 1995 X X X X X

Competency to stand trial

Golding et al., 1984 X X X X X

Civil competence

Schwartz and Barone, 1992 X X X X

Testamentary capacity

Spar and Garb, 1992 X X

ªquality of reasoningº indicated by weighing of risks and benefits. Absent from their scheme, however, is attention to the appreciation of the information to the subject's own situation.

Another problem is their inclusion of a reason-ableness of choice standard.

Wang and Ennis (1986) developed an elabo-rate ªcognitive competency testº which includes subtests designed to assess memory, reading skill, verbal reasoning, and spatial orientation.

The test is based on their multidimensional view of cognitive skills required for competence.

While their assessment scheme addresses only global competence, they do recommend com-bining this assessment with a more focused assessment of ªmental status.º However, little mention is made of matching specific situational demands with specific skill tests.

Draper and Dawson (1990) present an example of another assessment scheme: a flowchart for determination of competency.

The main decision nodes occur regarding understanding of illness and treatment alter-natives. Of interest is the inclusion of a question about acknowledgement of illness but one problem with this assessment scheme, in addition to extensive reliance on understanding, is the reliance on rationality of choice for competence determination.

Fitten and Waite (1990) assessed under-standing of various elements of the disclosure (the condition, the treatment, risks, benefits, and alternatives) and the ªquality of patient's or subject's reasoning processº (p. 1718). These authors hint at a distinction between ªbureau-craticº disclosure forms and forms geared toward patient understanding, but they do not expand upon the distinction. Prompting (cuing) helped their control group more than their hospitalized group. The hospitalized sample was impaired relative to controls on weighing of alternatives.

Like Wang and Ennis (1986), Freedman, Stuss, and Gordon (1991) identify attention, language, memory, and frontal lobe function as the ªcognitive functions underlying compe-tencyº and base their suggestions for assessment on these four areas. Once these abilities are established, ªthen issues related to judgment and awareness must be critically evaluatedº (p. 207). The result is a measure of global competence to the exclusion of situation-specific abilities.

A more recent system also relies upon understanding and little else. Janofsky, McCarthy, and Folstein (1992) base their assessment scheme on a quick measure of understanding of a disclosure. Comparison is made between their test instrument, the Hop-kins Competency Assessment Tool (HCAT),

and a forensic psychiatrist's assessment. Several criticisms have been made of HCAT. While it does assess understanding, other domains relevant to competence are unaddressed. Both Lavin (1992) and Sales (1992) note that reason-ing or rational weighreason-ing of choices is ignored.

Lavin also argues that relatively stable personal values are a required component of competence, one which HCAT does not measure. Englehart (1992) notes the lack of attention to the risk±benefit ratio of the choice in question, and Kaye (1992) notes that prognosis if no treatment is undertaken is not included in the HCAT disclosure vignette. Another problem of their assessment method is the potential for subjective error with their ªgold standardº of clinician judgment. Thus, at best HCAT can be considered a measure of understanding only, and not a measure of a more global concept of competence.

Some of the work reviewed above suggests another crucial element to consider when assessing competence: context. Appelbaum, Mirkin, and Bateman (1981) observed that ªThe stress surrounding any hospitalization, whether psychiatric or medical, may contribute to a failure of rational modes of thought, as may the necessity for making critical decisions from a position of relative ignorance about the medical issues involvedº (p. 1175). Empirical evidence supports this claim. According to Fitten and Waite (1990), the context of hospitalization impaired performance in gen-eral: in their sample of older adults, 28% of the hospitalized subjects had impaired performance on a vignette decision-making task despite no evidence of cognitive impairment on a standar-dized mental status exam or via clinical assessment (Fitten and Waite, 1990). Dellasega, Smyer, Frank, and Brown (1996) and Frank (1995) also found evidence of decision-making impairment despite relatively high mental status exam scores among their elderly hospitalized subjects. The specific causes of impairment (e.g.

the subject's illness, medical interventions) are unknown, but these studies suggest that hospitalized older adults are one group ªmost vulnerable to decisional impairmentsº (Fitten &

Waite, 1990).

Consideration of context in competence assessment is also crucial in long-term care settings. Increasingly the nursing home is recognized as a setting in which decisional capacity assessments are often required, and research suggests that three-quarters of nursing home residents exhibit some decisional capacity impairments (Goodwin, Smyer, & Lair,1995).

Pruchno, Smyer, Rose, Hartman-Stein, and Henderson-Laribee (1995) discuss methods that are objective, reliable, and easily administered

to assess decision-making ability of residents in nursing homes.

Appelbaum and Grisso (1995) have devel-oped three separate instruments for the purposes of assessing competence to provide informed consent, or more specifically, medical treatment decision-making capacity. The Un-derstanding of Treatment Disclosure (UTD) assesses capacity to understand relevant in-formation. The Perception of Disorder (POD) assesses appreciation of relevant information for the individual's own situation. The Think-ing Rationally About Treatment (TRAT) assesses the individual's ability to manipulate relevant information rationally. The TRAT represents an expansion of the quality of reasoning standard that is part of Stanley et al.'s (1984) scheme. Stanley and colleagues use comparison of risks and benefits as their indicator of quality of reasoning; the TRAT goes beyond that and includes other abilities as well: consequential thinking, complexity of thinking, and the ability to generate conse-quences for choices. The TRAT, POD, and UTD instruments provide a consistent method for assessment based on relevant legal criteria, but have not yet been normed for use with older adults.

7.06.5.2 Assessment of Other Types of Competence

Some researchers have recognized the need to match assessment to the specific competence ability under question (Grisso, 1994; Roth et al., 1977). As demonstrated above, the law increasingly recognizes that competence is not a global construct. Instead, competence may vary by content area within an individual. It is possible to find ªislands of competent functioningº (Gutheil & Bursztajn, 1986) in an otherwise incompetent individual. Attention to the context of the assessment is therefore desirable.

Civil competence, testamentary capacity, and competency to stand trial are all distinct concepts from competence to consent to treatment, but important work has been done in assessment of each of these types, and that work is relevant to the discussion here. The assessment of both civil competence and competency to stand trial share elements with several approaches to assessing capacity to consent to treatment. The Community Compe-tence Scale-Revised (CCS-R, Schwartz &

Barone, 1992) was developed to assess civil competence, and the Interdisciplinary Fitness Interview (IFI, Golding, Roesch, & Schreiber, 1984) was developed to assess competency to

stand trial. Both attempt to tie mental health issues to legal requirements by including assessment of psychological functioning. The CCS-R contains 17 subscales and the IFI contains 16, so while they clearly address global aspects of competence, the high degree of detail offers the potential for quite specific applica-tions. Further, by attending to both psycholo-gical and legal issues, they represent an attempt to bridge the divide between Faden and Beauchamp's (1986) two senses of consent and competence.

Spar and Garb (1992) state that to assess competence one must determine global mental status, assess specific aspects of mental func-tioning relevant to the ability in question, determine implications of those abilities for the specific context, and finally, form a diagnostic impression. Although it was devel-oped for the assessment of testamentary capacity rather than treatment, their assessment fits well with the four components discussed by Grisso (1994): diagnostic impression addresses the causal component, determining abilities relative to context addresses the interactive component, and the functional component is implied in the assessment of mental functioning.

Given their goal of presenting assessment consonant with current legal and social systems, the judgmental component is implied.

Several problems exist in most 1990s assess-ment schemes. First, rarely does assessassess-ment address all of the specific domains relevant to competence, that is, causal processes and interactive components as well as functional abilities. Instead, as noted above, many systems are based on assessment of global competence.

Individual-centered and contextually sensitive systems are rare. Second, few authors attend to the subjective components of their assessment schemes. As with definitions of competence, some assessment schemes allow societally determined standards of reasonableness or rationality to intrude. Third, criteria for success on an ability are often set casually rather than following formal investigation. The relative weight each ability should be given in an assessment is largely neglected. Fourth, there is a dearth of norms for older populations.

Thus, when gauging the functioning of older people, it is difficult to assess their relative standing.

Increasingly, psychological and legal con-ceptualizations of competence are being tied together. Linking the two increases complexity, but conceptualizations of competence have been improved by this increased attention to the relationship between psychological and legal issues. Rigorous investigation of defini-tions, standards, and assessment methods will

Assessment of Competence 123

further refine and improve our understanding of competence.

Miller and Cugliari (1990) surveyed long-term care facilities in New York State regarding treatment policies and found that only 12% of responding facilities had written guidelines for the determination of decisional capacity in 1986. By 1988 that number grew to 48%. The content of those policies varied, but of interest is the trend toward increased attention to for-malizing the assessment process through guide-lines. The question, however, is what should be contained in those guidelines? Additional empirical investigation of the concept of competence is required before that question can be answered.