Clinicians frequently make informal judgments about a patient's competence in their daily work; but some cases, such as treatment refusals or consents by questionably competent patients, necessitate formal, detailed assessments. Competence assessments should focus on the specific area of function in question. Assessments of global or general competence are unlikely to adequately respond to the presenting question. Among the procedural considerations in conducting competence assessments, the time and place of examination and the need for reexamination are especially important (Weiner and Wettstein). These assessments sometimes use written structured or formal assessment inventories of functioning, observational functional assessments (e.g., observing a patient grocery shopping and preparing a meal), psychological testing, or formal psychiatric interviews. History taking and collateral reports from third-party informants such as family, friends, and other healthcare personnel can be valuable additions to individual contact with the person being assessed. The examiner pays particular attention to eliciting information about the patient's decision-making history and the values he or she has placed on personal autonomy, healthcare, disability, and death. Consultations with colleagues or second opinions may also be helpful to the examiner in difficult cases. In general medical hospitals, competence assessments are conducted initially by nonpsychiatric physicians; if necessary, psychiatric consultants are called to assist in the evaluation.
Competence assessments raise many problematic clinical issues including denial of illness; subtle forms of incapacity; impact of elevated or depressed mood on decision-making capacity; fluctuating mental status (due to intermittent treatment compliance, the natural course of the disorder, or side effects of treatment); treatment refusals based on religious reasons; lack of information about the patient, including personal values and goals or history of treatment refusals; lack of formal staff training to do competence assessments; and disagreements among staff about the appropriate competence criteria or threshold. Typically, competence is not challenged, investigated, or formally assessed in clinical practice until a patient refuses treatment or is noncompliant with it.
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