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Medical Decision-Making Capacity Appears to Improve over Time

Categories: Cognitive Assessments - Thinking and Emotional Skills

The Question

How does medical decision-making capacity change during the first six months following traumatic brain injury?

Past Studies

Past Studies show that a brain injury can change the way an individual thinks, acts, and feels. Such changes often have an immediate impact on medical, financial, and other decision-making abilities. For some individuals, these impairments can last a long time after hospitalization. Of particular importance is medical decision-making capacity. Medical decision-making capacity (MDC) means the mental and emotional capacity of an individual to agree to or refuse, a specific medical intervention. MDC requires four abilities. An individual must be able to: communicate a choice, judge the outcomes of that choice, reason about different treatment choices, and understand the treatment situation and choices. Clinical issues concerning MDC are common with traumatic brain injury. Immediately following an injury, medical personnel may perform emergency life-saving procedures without the individuals’ or family participation. However, shortly after individuals are medically stable they are considered to possibly participate in a range of medical decisions. If the individuals do not possess the skills for medical decision-making, a family member or a legal representative will make the decisions for them. Further, questions about the individuals’ capacity for making medical decisions for others, such as for their children or spouse, also arise. A significant problem for rehabilitation clinicians in determining whether individuals have recovered enough to make their own medical decisions. Although some research has been conducted on individuals with dementia, there is little research on MDC loss and recovery for individuals with traumatic brain injury.

This Study

This study examined the MDC for individuals with and without traumatic brain injury. Twenty-four individuals with moderate to severe traumatic brain injury were compared to a group of individuals with similar characteristics who did not have a brain injury. Both groups were assessed with the Capacity to Consent to Treatment Instrument (CCTI) as well as standard tests of thinking ability and emotional processing at the time of hospitalization and six months later. The CCTI evaluates the performance of the four accepted consent abilities for MDC (listed above), and one experimental standard, the ability to make the reasonable treatment choice when the alternative choice is unreasonable. In addition, the individuals with traumatic brain injury were rated as capable, marginally capable, or incapable for each of the four abilities. At the end of the project, the researchers compared the results between the two groups.The individuals with brain injury were able to communicate a choice and make the reasonable choice when the alternative choice was unreasonable at the time of inpatient rehabilitation. They had impaired abilities regarding judgment, reasoning, and understanding for consent. Over the six-month period, the group showed improvement in these areas. However, the improvements only represented a partial recovery. The researchers state that patients and their significant others should be educated about MDC recovery in the inpatient setting to fully equip them to plan for the future.

Who May Be Affected By These Findings

Individuals with traumatic brain injury and their significant others, health care providers, attorneys, researchers, hospital, and rehabilitation center ethics committees

Caveats

This study is limited because it included a small number of participants. A similar study using a large group of participants could produce results that are generalizable. Additionally, a similar study that tracked the recovery process for longer than six months may provide evidence for serial documentation of MDC. With documented improvements, perhaps more individuals could participate and eventually resume independent MDC.

Bottom Line

The individuals with brain injury had significant impairment in MDC at the time of their injury, with partial recovery of MDC over a six-month period.

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Find This Study

Marson, D. C., Dreer, L. E., Krzywanski, S., Huthwaite, J. S., Devivo, M. J., & Novack, T. A. (2005). Impairment and partial recovery of medical decision-making capacity in traumatic brain injury: A 6-month longitudinal study. Archives of Physical Medicine and Rehabilitation, 86, 889-895.

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