Blog by Robert C. Abrams, Pamela Ansell and Veronica Lo Faso
Division of Geriatrics and Palliative Medicine, Weill Cornell Medicine, New York, NY USA
As global attention is directed to the mistreatment of older adults on June 15, World Elder Abuse Awareness Day, it is timely to consider how victims of abuse and neglect make decisions about the risks they face and the services that are offered to protect them. In most states in the U.S., decisional capacity is determined on a decision-by-decision basis by physicians or clinical psychologists. However, in their evaluations of older victims of abuse, neglect or exploitation, Adult Protective Services (APS) workers are often tasked with making initial, “on the ground” assessments of decisional ability, especially when they find that client-victims are refusing vital services.
In fact, the refusal by some older victims of mistreatment or neglect to accept emergency services or interventions is a nearly universal problem encountered by APS workers in the field. In this way APS workers find themselves burdened with the responsibility of making the first attempts to resolve a fundamental tension: that between the liberty to refuse services, or the right of self-determination, and society’s responsibility to assure the well-being of its most vulnerable citizens.
However, without a systematic approach, decisional ability assessments can produce unreliable or invalid conclusions, resulting, for example, in accepting the refusal of services from a client who lacks the ability to make such decisions, or wrongly finding a client unable to make a particular decision. Few APS agencies in the U.S. have trained workers in the skills required to assess decision-making abilities, and a standardized tool has not been developed to support them. Many APS organizations have relied on cognitive screens or “gut feelings” to make such determinations, but these methods use domains that are often peripheral to the process of decision-making.
Nevertheless, gathering information about decision-making abilities is critical to the assistance of mistreated older adults. To address this problem, our group at Weill Cornell Medicine in New York and the Perelman School of Medicine at the University of Pennsylvania developed the Cornell-Penn Interview for Decisional Abilities (Cornell-Penn IDA), a semi-structured interview, and an online training curriculum to accompany it. Adapted from a template created by Karlowish and colleagues (Lai JM, Gill TM, Comey CM, Bradley EH, Hawkins KA, Karlawish JH. Everyday decision-making ability in older persons with cognitive impairment. Am J Geriatr Psychiatry. 2008 Aug: 16(8): 693-696. Doi: 10.1097/JGP. 0b013e31816c7b54), the Cornell-Penn IDA is designed to guide APS workers in evaluating the decisional abilities of adult clients suspected of mistreatment. The only inclusion requirement for its use is a general one: Clients must be able to participate in a material conversation about the risks they face. Each Cornell-Penn IDA interview focuses on the client’s single most imminent risk.
The Cornell-Penn IDA, described in greater detail elsewhere (Abrams RC, Ansell P, Karlawish J, Breckman R, Lachs M, Holt-Knight D, Needell N, Rogers G, Lo Faso V. The Interview for Decisional Abilities (IDA): A tool to assess the decisional capacity of abused and neglected older adults. Journal of Elder Abuse and Neglect. March 1, 2019. Doi_abs_10.1080_08946566.2019.1573392-3F), follows a well-established sequence of three components of decision-making, including: understanding the general problem or risk; appreciation or insight into the personal implications of the risk; and reasoning through the advantages and disadvantages of a plan to address the risk (Grisso T, Appelbaum PS. Comparison of standards for assessing patients’ capacities to make treatment decisions. Am J Psychiatry 1995. 152:1033, Grisso T, Appelbaum P. (1998). Assessing Competence to Consent to Treatment: A Guide for Physicians and Other Health Professionals. New York: Oxford University Press). The semi-structured format of the tool encourages meaningful, client-centered conversations. Using this approach, the Cornell-Penn IDA’s assessment of decisional ability is built around the person’s own wishes, goals and experiences, and also takes into account the severity and possible consequences of the risk under discussion. The two basic outcomes of the Cornell-Penn IDA encounter are: 1) acceptance of the client’s decision regarding his or her own circumstances; or 2) referral for professional capacity assessment, typically by a psychiatrist, licensed clinical psychologist or general physician. In some cases, evaluation for judicially determined guardianship must also be considered.
Although the Cornell-Penn IDA has to date been trialed as a tool for APS workers assessing older adult victims of abuse or neglect, the same model could also be relevant to the assessment of decisional ability in a broader range of settings. It is anticipated that future applications of the tool will be positioned to encompass medical, financial and testamentary decision-making.