Assessing client competence to participate in rehabilitation decision making

Numerous persons receiving rehabilitation services demonstrate compromised judgmental or cognitive ability which occasionally casts doubt on the validity of their consent to, or refusal of, rehabilitation treatment. A 14-member panel of nationally recognized forensic and neurorehabilitation experts (recruited from physiatry, law and mental health) viewed 21 videotaped competency interviews of cognitively impaired inpatients in an acute care rehabilitation hospital. Each rater offered an opinion on whether the interviewee was competent or not based on background history and the interview format presented here. Their ratings are compared with those of the interviewees' treating professionals, who based their competency assessments on their day-to-day clinical interactions with the patients. Results showed similar judgments among the three groups of videotape raters but statistically significant differences between the ratings of the panel members and the patients' treatment team. Reasons for these discrepancies are explored with additional comments on the conceptual obstacles presented by competency assessments in general. This article also describes a brief evaluation of competence to consent to treatment developed during the research program with input from the panel of experts. Qualified rehabilitation providers might employ such techniques to assess competence to participate in medical decision making.