Introduction: The concept of capacity and the corresponding ability to make independent decisions regarding healthcare and finances is complex, and currently has no clear “gold standard” for assessment. Patients’ mental states and their capacity may change. This can lead to difficulties in managing their care, throughout treatment and particularly towards palliation and end of life.
Case description: Mr SC was a 75 year old man with epitheliod malignant mesothelioma. This was treated with standard chemotherapy, however after thirteen months of treatment he progressed and became palliative. His treatment was complicated by his wife and enduring power of attorney (EPOA) who refused to allow him to be managed with opioids. When alert and compos mentis he requested opioids for pain and dyspnoea management; however once sedated, his wife would order their cessation. This culminated in the patient being independently assessed by a geriatrician and occupational therapist to determine his capacity. Once found to be of sound mind, he changed his EPOA so as to allow himself to be palliated effectively.
Discussion: The methods and tools used to assess patients and their capacities are varied. These range from the mini mental state examination and montreal cognitive assessment to neuropsychological evaluation1,2,3. Currently there is no “gold standard” assessment tool for determining capacity, and the general consensus consists of a multifactorial approach, with both medical and legal evaluations4. In assessing capacity, it is important to bear in mind one should not infer an overall lack of capacity from lack of capacity in a specific area5. Upholding a person’s autonomy and right to make their own healthcare decisions is paramount6. This case highlights the complexities involved with assessment, and the need to focus on patients, their needs and best interests.