Assessment of fluctuating decision-making capacity in individuals with communication barriers: a case study

A current need exists for research to assist clinicians in the capacity evaluation process, especially in relation to assessment of clients with complex issues such as fluctuating capacity and communication barriers. The aim of this article is to promote knowledge and consideration of these issues through an examination of neuropsychological, ethical, and medical-legal factors associated with the assessment of capacity in an individual with both fluctuating capacity and communication impairments. The discussion includes a narrative case study of a complex individual case seen by the Regional Capacity Assessment Team (RCAT) for an assessment of decision-making capacity related to personal and financial matters. Relevant background information about this client, behavioral observations, neuropsychological test results, and the process and outcome of the RCAT targeted capacity interview are presented. Based on previous literature and the case study, a series of recommendations are provided to guide the clinician through the capacity evaluation process with individuals with complex issues. Common pitfalls, nuances, and dilemmas involved in capacity assessment are addressed.