Cognitive models of physicians' legal standard and personal judgments of competency in patients with Alzheimer's disease

OBJECTIVES: To investigate measures of patient cognitive abilities as predictors of physician judgments of medical treatment consent capacity (competency) in patients with Alzheimer's disease (AD). DESIGN: Predictor models of legal standards (LS) and personal competency judgments were developed for each study physician using independent neuropsychological test measures and logistic regression analyses. SETTING: A university medical center. PARTICIPANTS: Five physicians with experience assessing the competency of AD patients were recruited to make competency judgments of videotaped vignettes from 10 older controls and 21 patients with AD (10 with mild and 11 with moderate dementia). MEASUREMENTS: The 31 patient and control videotapes of performance on a measure of treatment consent capacity (Capacity to Consent to Treatment Instrument) (CCTI) were rated by the five physicians. The CCTI consists of two clinical vignettes (A-neoplasm and B-cardiac) that test competency under five LS. Each study physician viewed each vignette videotape individually, made judgments of competent or incompetent under each of the LS, and then made his/her own personal competency judgment. Physicians were blinded to participant diagnosis and neuropsychological test performance. Stepwise logistic regression was conducted to identify cognitive predictors of each physician's LS and personal competency judgments for Vignette A using the full sample (n = 31). Classification logistic regression analysis was used to determine how well these cognitive predictor models classified each physician's competency judgments for Vignette A. These classification models were then cross-validated using physician's Vignette B judgments. RESULTS: Cognitive predictor models for Vignette A competency judgments differed across individual physicians, and were related to difficulty of LS and to incompetency outcome rates across LS for AD patients. Measures of semantic knowledge and receptive language predicted judgments under less difficult LS of evidencing a treatment choice (LS1) and making the reasonable treatment choice (LS2). Measures of semantic knowledge, short-term verbal recall, and simple reasoning ability predicted judgments under more difficult and clinically relevant LS of appreciating consequences of a treatment choice (LS3), providing rational reasons for a treatment choice (LS4), and understanding the treatment situation and choices (LS5). Cognitive models for physicians' personal competency judgments were virtually identical to their respective models for LS5 judgments. For AD patients, shortterm memory predictors were associated with high incompetency outcome rates (over 70%), a simple reasoning measure was associated with moderately high incompetency outcome rates (60-70%), and a semantic knowledge measure was associated with lower incompetency outcome rates (30-60%). Overall, single predictor models were relatively robust, correctly classifying an average of 83% of physician judgments for Vignette A and 80% of judgments for Vignette B. CONCLUSIONS: Multiple cognitive functions predicted physicians' LS and personal competency judgments. Declines in semantic knowledge, short-term verbal recall, and simple reasoning ability predicted physicians' judgments on the three most difficult and clinically most relevant LS (LS3-LS5), as well as their personal competency judgments. Our findings suggest that clinical assessment of competency should include evaluation of semantic knowledge, verbal recall, and simple reasoning abilities.