Evaluation of legal competency in patients with frontal lobe injury

In recent decades, the relationship of the patients and health care provider has evolved into an informed, collaborative effort to recover from illness. The movement of patients from passive to active participants in treatment planning has caused an increasing need for patients to be competent, to successfully perform often complex analysis of available options, risks inherent in these options, and potential benefits of choosing one course of action over another. While competency is determined by the courts, the courts rely heavily on the opinions of health care providers with expertise regarding mental and emotional processes. Thus, knowledge of both legal standards of competency and of the mental and emotional processes which support competency have become increasingly important. Competency has been held to be comprised of perception and comprehension of a relevant body of information; memory and recall of relevant information well enough to support further mental evaluation of the information; the capacity to identify personal options implicit in the information and to logically deliberate among the available options based on relative potential risks and the benefits; and the capacity to make an enduring decision based on prior logical deliberation. The assessment of competency is even more difficult in the patient with executive dysfunction. Neuropsychological assessment, which is traditionally used to assess cognitive functioning, has not been as helpful in the quantification of the patient's ability to solve problems in a logical manner. This paper will outline the requisite steps in assessing competency and review the current data available on the neuropsychological assessment of frontal lobe dysfunction in competency determination.