Capacity to Make Treatment Decisions
A family physician refers you, a home care dietitian, to provide education to a 49-year-old client with a developmental disability who lives alone for nutrition management of newly diagnosed insulin-dependent diabetes. The client is able to provide what seems like an accurate record of their daily food intake.
When you explain the relationship of food intake to insulin, the client becomes quite agitated. The client repeats several times that they had no idea that "this diet would be forever" and that wants to eat like a “regular person”. When you try to reassure them that you will work with them to set up something that they will be able to follow, the client begins to cry.
At the next visit, you try to illustrate a few concepts. Again, the client is distressed and states that they don’t believe that “this diet stuff” is important and they don't think anything will happen if they skip meals and then take their insulin. After the visit, you contact the referring physician, who says that he feels the client is capable of understanding their diabetes and the treatment implications. The physician reiterates that the diet is an essential component of the client’s treatment. You call the home care nurse, who says that the client is able to draw and inject insulin independently. The nurse tells you, however, that the client lives close to a sibling and that the sibling is involved in some aspects of the client’s care. What do you do?
The scenario, “Capacity to make treatment decisions”, illustrates the complexity of determining whether a client is capable of giving informed consent for a particular treatment. Sometimes clients can be capable for some decisions and not others.
The key issue in this scenario is whether the client understands and appreciates the consequences of their decision about the treatment. The client’s statement at the second visit, that she does not believe that the diet is important and she does not think anything will happen if meals are skipped and insulin is taken, raises serious doubts about whether the client appreciates the consequences of their decisions. The dietitian, while considering the views of the referring physician and the home care nurse, has to make his or her own assessment of whether the client is capable of making this particular decision. If you determine that a client is not capable, then you must obtain consent from the appropriate substitute decision-maker. (Refer to the Professional Practice Standard, Consent to Treatment, Standards 1, 3-5 and 7) .
Sometimes, there is confusion about the role of the Consent and Capacity Board in making findings of incapacity. Unless the Board has made a general finding of incapacity about the client, it is the responsibility of the front-line practitioner to determine the client's capacity for an individual treatment proposed. In this case, you would not determine the client's general capacity, but rather whether the client was capable of making a decision about the specific dietary changes being recommended.