1402 - A multidisciplinary approach to capacity evaluation in the setting of non-traumatic brain injury

Case Diagnosis: Cerebellar infarct with hemorrhagic conversion

Case Description: 61-year-old gentleman with hypertension and pre-diabetes presented as a stroke code. CT revealed cerebellar stroke and Tenecteplase was administered. This resulted in hemorrhagic conversion with mild hydrocephalus requiring medical management and suboccipital craniectomy.

He presented to acute rehabilitation with left hemiparesis, dysarthria, dysphasia, behavioral/affective changes, and cognitive impairment including decreased executive functioning. A&Ox2 and pleasant, with fluctuating agitation and mental status.

Patient’s family requested a healthcare proxy (HCP) form be completed. Due to intact superficial interactions, the consensus of the treatment team was that the patient had capacity. The primary resident performed a capacity evaluation and determined he lacked capacity. The patient could not demonstrate decision making consistency. Becoming a barrier to discharge, neuropsychology was consulted to perform a formal capacity assessment. The findings included inconsistent decision making with impaired awareness and reasoning. These were confidently relayed to the family and the rest of the treatment team.

Discussions: The patient’s presentation displayed components of Cerebellar Cognitive Affective Syndrome (CCAS). The primary resident’s examination and neuropsychology’s examination were able to corroborate that the patient lacked capacity to make a decision regarding assigning a HCP. These findings differed from the team’s consensus prior to examination but this corroboration increased the reliability of the capacity examination and enhanced the confidence the treatment team and family had in the result.

Conclusions: This case draws on existing capacity literature which supports how an interdisciplinary approach, which combines traditional methods and neuropsychological testing, can provide a more thorough evaluation and better serve the patient.