To the Editor:
I thoroughly enjoyed the Psychiatry Rounds article “Decision-Making Capacity.”1 I would like to ask the following:
1. Do you personally use the MacArthur Competence Assessment Tool for Treatment (MacCAT-T) (I was thinking of purchasing the interview for our use), or do you prefer another assessment tool?
2. Generally, in what instances, if any, do you feel that the MacCAT-T is not sufficient and neuro-psychiatric testing is warranted?
Paula Bordelon, DO
Sacred Heart Hospital
1. Lantz MS. Decision-making capacity. Clinical Geriatrics 2006;14(2): 15-18.
Dr. Lantz responds:
Thank you for your very relevant questions. The assessment of decision-making capacity is often a very emotional issue, as we are commonly asked to perform such evaluations when there is conflict between the patient, family, and treatment team. Like many clinicians, I do not use one tool for the evaluation of decision-making capacity. It is most important to keep in mind that any evaluation of decision-making capacity should be as specific as possible. Often clarifying the specific issue in question is helpful to both the treatment team and the patient. Using the basic model of: Understanding, Appreciation, Reasoning, and Communication, an evaluation of decision-making capacity can be made in almost every case.1,2 The MacCAT-T, which utilizes these four basic items, offers clinicians a semi-structured interview with prepared forms and a rating scale for evaluating responses.2 Many clinicians find that reviewing the scale and interview questions is beneficial in performing evaluations. At times, it may be necessary to evaluate the patient on more than one occasion, and at varying times of the day. Neuropsychological testing is usually utilized in cases where the diagnosis is unclear, or if the patient presents with cognitive deficits of an unusual nature. Given the wide variety of decisions that patients must make under varying circumstances, it is important to clearly identify the issue in question and perform a careful clinical evaluation under the most controlled circumstances possible. Utilize the interdisciplinary team and significant others for collateral information, and then listen to the patient.
Melinda S. Lantz, MD
Series Editor, AAGP Psychiatry Rounds
Director of Psychiatry
The Jewish Home & Hospital
New York, NY
1. Vellinga A, Smit JH, van Leeuwen E, et al. Instruments to assess decision-making capacity: An overview. Int Psychogeriatr 2004;16(4):397-419.
2. Grisso T, Appelbaum PS. Appendix manual for the MacArthur Competence Assessment Tool-Treatment (MacCAT-T). In: Grisso T and Appelbaum PS, eds. Assessing Competence to Consent to Treatment: A Guide for Physicians and Other Health Professionals. New York: Oxford University Press; 1998:127-148.