I Hate the Term “Sober And Competent” Part II

In Part I, I tried to explain why I think the term “soberandcompetent” is not a useful one. It is more important to assess whether a patient has decision-making capacity.  Capacity entails the ability to absorb the medical information, synthesize it into information that is meaningful, and make a decision based on the new data.  Simply, does the patient understand and appreciate what is going on and communicate their choice?

I hate to say this, but in the end it is all a grey area.  You are going to have to make a judgment call.  There is not a list of approved questions that all need to be answered quickly and correctly for a patient to have capacity.  It would make your job easier if such a list existed, but your job is hard.  EMS providers must be able to describe the reasons that they think the patient has or lacks decision-making capacity.

I try to answer that question on two levels.  First are the general orientation questions. For someone to have decision-making capacity, they should be generally oriented:

• What day of the week is it? (Not date.  I hate when people ask the date of patients.  Shit, I only know the friggin’ date plus/minus two days…)
• Where are you right now? (What's a correct answer? Country? State? City? In an ambulance? Do they have to know the intersection?)
• What is your name? (How do you know what the right answer is?  I try to only ask questions that I know the answer to...)

I add other questions that help assess whether the patient’s brain is working as it should.  Competent decision makers should be able to handle simple questions. For example:

• How many quarters are in a dollar-fifty?
• Who is the president?
• Who plays quarterback for the Broncos? (Change the team name to one important to your city. I find "Dunno, I don't like football" works. They translated Bronco to football, which is a correct answer.)
• Name a sports team. Any sports team.
• What holiday did we just have? (Be careful: This is unhelpful in months without important holidays and is kind of a Eurocentric question.  I mean, if the patient's answer is "Maha Shivaratri" are you going to call bullshit?)

These kinds of questions show more than whether a patient can perform simple math or regurgitate a politician’s name.  They require translation from one level of thought to another.  The patient has to translate dollars to quarters.  The patient has to translate Broncos to Manning, or sport to baseball to New York Yankees.  Most importantly, they are all questions that anyone can answer.  My grandmother hates sports, but can name the Yankees.

Everyone can name the New York Yankees and the Regina Butter Churners Hockey Club, right?
(By Knipple23 (CC-BY-SA-3.0), via Wikimedia Commons)

It isn’t an interrogation.  I tell people flat out that I need to check how well their brain is working and ask the questions with a smile.  Their answers may lead to jokes or other conversation. 

People should be able to answer simple questions like this without too much trouble.  I give folks wiggle room, if they have good reason.  Everyone should know that six quarters make up a buck-fifty, but not all nursing home denizens know the day of the week.  If you don’t have a job, or other reason to know what day it is, who cares?  If someone names the president-elect rather than the president in December 2016, I'm not going to chicken-wing them off to the hospital.  I base my capacity decision as to how much their answers make sense.  Grey areas, baby!

All of this is a grey area (all of EMS is one big grey fog bank), but if a patient doesn’t know that two days ago was Christmas then I have to question their decision making capacity (even if they are not observant Christians).  If they say that there are four quarters in a dollar-fifty, or if they think entirely too hard to come up with six quarters, then I have to question whether they can understand and appreciate what is going on.

If they are just uncooperative asses and refuse to answer the questions, I have to question whether they can understand and appreciate what is going on.

If they answer those kinds of questions well, I need to move to the second level of decision-making assessment.  This level of capacity-assessing questions involve the decision itself:

• Tell me in your own words what I think is wrong with you. (This is checking whether they can take the information that you gave them, absorb it, and give it back to you in a way that makes sense. I don't care whether they agree with my opinion; I care whether they heard my opinion.)
• What is my opinion of what might happen if you don’t go to the hospital. (I don't care what they think.  I care that they have heard my worst fear.)
• What do you think will happen to you at the hospital?  If you stay home? (With this, I am just curious about what they are thinking.)
• Help me understand why you want to stay home. (Just ask the question straight out.)

A patient doesn’t have to agree with me as to what is wrong, or about what may happen.  They have to be able to show that they absorbed the information accurately and can communicate their decision.

From that point, after I have assessed the patient’s level of orientation and whether the patient can understand what is going on and make a reasoned choice about their medical care, I need to make a decision of my own: Does this patient have the capacity to make a decision about their care?  If I think they do, I need to be an advocate for their position. 

Remember, it is a grey area.  If I have doubts, the patient probably doesn’t have the capacity to safely make decisions for themselves.  See what your partner thinks.  See what the cop on scene thinks.  Their opinions can be helpful, especially if they can explain them.  If worse comes to worse, I can contact base and get a second opinion from the physician that answers the phone.

The kinds of questions listed above are helpful in another way.  The answers to the questions help me to explain why I think the patient possesses capacity.  I will have to do it on the patient care report, and may have to do it on a biophone report too.  I never say that the patient is “soberandcompetent.”  That term is unhelpful.  People respond better when I state that “…I believe the patient has decision making capacity…”  If I am asked why I think that, I can explain my decision because I asked a whole bunch of questions.  I can explain because I explored the specifics of the patient’s level of orientation and their decision making process.  I know that they can absorb accurate information and make decisions based on the information.  And I can describe that process. 

So, does the patient in Part 1 have decision-making capacity?  I don’t think so.  Hallucinating is not a sign of clear thinking.  The patient didn’t make the decision, the cat did.  So the invisible cat can stay at home, but the patient would be coming with me to the hospital.