The Hopkins Competency Assessment Test:

A Brief Method for Evaluating Patients’

Capacity to Give Informed Consent
Jeffrey S. Janofsky, M.D. years the doctrine of informed con- The questionnaire that follows
sent has established that patients
Richard J. McCarthy, M.D. the essay is written at the sixth-grade
should understand a description of reading level. It includes true-false
Marshal F. Foistein, M.D.
the proposed treatment and should and sentence-completion questions,
be aware ofits risks, benefits, and al- some of which have more than one
The Hopkins Competency Assess- ternatives. To be valid, informed part. Subjects score 1 point for each
ment Test (HCAT), a brief instru- consent must be voluntary, and pa- correct answer. Possible scores on the
mentfor evaluating the competen- tients must be competent to under- questionnaire range from 0 to 10.
9’ ofpatients to give informed con- stand the discussion ofthe treatment The essays were designed for dif-
sent or write advance directives, and the right to informed consent. ferent reading levels because the
consists ofa short essay and a ques- Although judges ultimately de- literature indicates that comprehen-
tionnaire for determining pa- cide whether a patient is competent,
sion of instruments depends directly
tients’ understanding of the essay. physicians are often asked for an
In a study to validate the instru- on readability (2-7). We chose to
opinion, based on their medical cx-
ment, 41 medical and psychiatric offer the HCAT at high, middle, and
pertise, about a patient’s competen-
inpatients answered the question- low reading levels rather than only at
cy. Quantitative scales that assist
naire after reading the essay while a low reading level because our pilot
physicians in judging apatient’s cog-
hearing it read aloud. A forensic data showed subjects with high
nitive capacity and capacity for ac-
psychiatrist who was blind to the educational attainment bad difficul-
tivities of daily living are available,
HCAT scores later examined the ty comprehending the version writ-
but there are as yet no quantitative
patientsfor competency. A subject’s ten for persons with a low reading
scales for assessing clinical com-
number of correct answers to the level. The HCAT essays are shown in
petency, which is sometimes called
HCAT questionnaire was an ac- Table 1 and the questionnaire
, is
clinical capacity. We report here the
curate indicator of clinical corn- shown in Table 2. Essays were
results ofa study validating the Hop-
petency as assessed by the psychia- printed in large type (14 point) to
kins Competency Assessment Test, a
trist. The results suggest that the new instrument for quantitative as- minimize effects of visual impair-
HCAT is a useful too/for rapidly ment.
sessment of clinical competency.
screening patients for competency This test does not determine legal Subjects. Patients on a general
to make treatment decisions. medical ward and a general and geri-
competency but rather is an aid to
the clinician in forming an opinion atnic psychiatry ward at the Johns
about clinical competency. Hopkins Hospital were asked to par-
Adult patients have the right to
ticipate in the study. Inftrmed con-
decide whether they will undergo a
Methods sent was obtained from all partici-
medical treatment. In the past 30
instrument. The Hopkins Compe- pants, following the procedure ap-
tency Assessment Test (HCAT) was proved by the Hopkins Institutional
Dr. Janofsky is assistant professor developed to screen patients fbr corn- Review Board. We collected demo-
of psychiatry and behavioral sci- petency to make treatment decisions graphic and clinical information on
ences and Dr. Foistein is Eugene and to write advance directives. The all research subjects. Subjects also
Meyer III professor of psychiatry instrument consists of a short essay completed the Mini-Mental Status
and medicine at Johns Hopkins describing informed consent and Examination (MMSE), a brief test
University School of Medicine in durable power of attorney, followed of cognitive functioning. Possible
Baltimore. Dr. McCarthy is a res- by six questions about the material scores on the MMSE range from 0 to
ident in psychiatry at George presented in the essay. Versions of 30, with scores less than 24 indicat-
Washington University in Wash- the essay at the 13th-grade, eighth- ing impaired cognitive fimctioning.
ington, D.C. Address correspon- grade, and sixth-grade reading levels Procedure. Data were collected in
dence to Dr. Janofsky at Meyer were prepared. The grade levels were April 1990 on 12 days when both cx-
144, Johns Hopkins Hospital, 600 determined by the Flesch-Kincaid aminers were available. On the days
North Wolfe Street, Baltimore, method using the Grammatik III data were collected, we attempted to
Maryland 21205. Computer Program (1). enroll all new patients admitted to

132 February 1992 Vol.43 No.2 Hospital and Community Psychiatry

Table 1
Essays at three reading comprehension levels presented to patients as part of the Hopkins Competency Assessment Test

Thirteenth grade Eighth grade Sixth grade

Before undergoing a medical procedure, Before a patient has a medical proce- Before a doctor can do something to a
a patient must be informed about the dune, he must be told about the proce- patient, he must tell the patient what he
procedure. The patient must under- dune by the doctor. The patient must is going to do. The patient must know
stand what the procedure is about, the know what the procedure is and what what the doctor is going to do, what
risks ofthe procedure, the benefits of the could go wrong. The patient should also could go wrong, what could go right,
procedure, and alternatives to the proce- know what are the good things that and what else the doctor could do in-
dure. After learning about the proce- could happen as a result ofthe procedure stead. After the doctor tells the patient
dune the patient then has the option of and what else could be done instead of these things, the patient may agree to
agreeing to go fbrth with the procedure the procedure. After the patient finds let the doctor go ahead. Or the patient
or not. out about the procedure from his doctor can tell the doctor not to go ahead.
the patient then can decide whether to
Patients with chronic disease may lose have the procedure done or not. Some patients have been sick for a long
the ability to understand the informa- time. After a while their thinking
tion necessary to make responsible dcci- Patients who are sick for a long time might not be so good. At that time, the
sions regarding their own health care. may not be able to understand what the patient might not be able to think well
When that time comes they will not be doctor tells them about what might enough to understand what his doctor
able to consent to medical treatment need to be done. When this happens says. When that time comes he will not
and this power must then be delegated some patients are not able to give per- be able to let the doctor know what he
to someone else. mission to their doctors to have certain wants the doctor to do.
tests or procedures done. Then someone
Patients can leave formal legal instruc- else has to make their decisions for Well patients can tell their doctor what
tions regarding what they would want them. they want the doctor to do. Well pa-
to have done in specific medical situa- tients can also tell their doctor which
tions and who they would want to make There are two things such patients can person they would like for the doctor to
such decisions if they become unable to do. First, the patient can tell the doctor talk with when the patient is not able to
make them themselves. Such instruc- who he wants to make decisions for him let the doctor know that he wants done
tions are called a durable power of attor- if he is unable. Second, the patient can himself. Such things need to be written
ney. tell the doctor directly what he wants down on paper. This paper is called a
done if he becomes unable to make deci- durable power of attorney.
The durable power of attorney allows sions himself. These instructions are
patients to designate who will make called a durable power of attorney. The durable power of attorney lets pa-
medical decisions for them and what tients say who will tell the doctor what
limitations, if any, are placed on the de- The durable power of attorney lets pa- to do if the patient can’t tell the doctor
cision making authority. tients decide who will make medical de- himself. The durable power of attorney
cisions for them if they are unable. It also lets a patient say now what he wants
also lets the patient decide what the to have done and what he doesn’t want
patient himself wants to have done if he to have done if he gets sick.
is unable to make decisions.

the wards being studied. A medical examination ended and that score dency and a fellowship in forensic
student (RJM), trained to administer was recorded. If the subject scored 7 psychiatry and had three years of
the HCAT, gave the test. or less, the examiner read aloud the subsequent experience in the assess-
The examiner asked each subject sixth-grade version, administered ment of clinical competency. The
to read the 1 3th-grade version of the the questionnaire, and recorded the purpose ofthe examination was toes-
HCAT while the examiner read the patient’s score. tablish a standard by which to vali-
material aloud. The HCAT was read Interobserver reliability of the date the HCAT questionnaire re-
to the subject to eliminate illiteracy HCAT was tested by comparing sults. The forensic psychiatrist was
as a confounding factor. The HCAT scores on questionnaires adminis- blind to the results ofthe HCAT cx-
questionnaire was then read to the tered by two examiners (RJM and amination and to the patient’s demo-
subject. If the subject scored 8 or JSJ) to a pilot group of subjects. graphic and clinical data and MMSE
higher, the examination ended and Within 24 hours ofthe HCAT cx- score.
that score was recorded. amination, a forensic psychiatrist The forensic psychiatrist’s cx-
If the patient scored 7 or less, the (JSJ) experienced in clinical com- amination consisted ofa brief history
examiner read aloud the eighth- petency examinations performed a and mental status examination as
grade version of the HCAT and ad- clinical competency examination on well as questions to determine the
ministered the same questionnaire. each subject. The forensic psychia- subject’s competency to consent to
If the subject scored 8 or higher, the trist had completed psychiatric resi- medical treatment and to write a

Hospital and Community Psychiatry February 1992 Vol.43 No.2 133

 ence=1.07, df=39, ns). Mean±SD
Table 2 MMSE scores for those populations
Questionnaire assessing respondent’s understanding of essay presented in the Hopkins were 19.44±11.13 and 22.4±6.11
Competency Assessment Test1
(t=.28, SE ofthe difference=2.60,
Question Answer df= 39, ns). Thus similar ranges of
scores were found in both groups, in-
What are the four things a doctor must What the doctor is going to do. dicating that designation as a psychi-
tell a patient before beginning a proce- What could go right.
atnic or medical patient did not
dure? What could go wrong.
predict scores on either the HCAT or
What else the doctor could do instead.
MMSE. Figure 1 shows a scatter plot
(1 point for each correct answer)
representing each subject’s HCAT
True or false: After learning about the True (1 point for correct answer) and MMSE score and the result of the
procedure, the patient can decide not to forensic psychiatrist’s competency
have the procedure done. assessment.
What can sometimes happen to the After a while, the patient’s thinking We found that all 14 incompetent
thinking ofa patient who has been sick may not be as good as it is now. (1 point patients scored 3 or less on the
for a long time? for correct answer) HCAT. The remaining 27 patients,
who were rated clinically competent,
Finish the sentence: A patient whose Tell the doctor what the patient wants
scored 4 or more. The results suggest
thinking gets bad may not be able to done. (1 point for correct answer)
that the HCAT has a sensitivity and
specificity of 100 percent when a
What two things should such patients Patients can write down who else the cutoff score of 4 is used to indicate
tell their doctor and fmily, before their doctor can talk to in order to make med- competency.
thinking gets bad? ical decisions for them. To compare the accuracy of the
Patients can write
down what medical MMSE and the HCAT, patients’
procedures want to have done or
they MMSE scores were compared with
not have done. (1 point for each correct the results ofthe psychiatrist’s assess-
answer) ment. Using a MMSE score of 9 or
What are these instructions to doctors They are called durable powers of attor- below to indicate patients who are
and family called? ney. (1 point for correct answer) not competent resulted in a 100 per-
cent sensitivity but only a 36 percent
1 Possible scores range from 0 to 10. specificity. Conversely, when the
cutoffpoint for competency was set
at 24 on above, specificity of the
durable power ofattorney. The psy- in other primary organ systems, in- MMSE increased to 100 percent but
chiatnist scored the examination by cluding the cardiovascular, respira- sensitivity dropped to 74 percent. As
generating a categorical assessment tory, gastrointestinal, and endocrine can be seen in Figure 1 there was
,

ofcompetent or not competent. systems. considerable overlap between pa-

The validity ofthe HCAT was cx- The meani±SD age ofsubjects was tients judged competent and incom-
amined by comparing each subject’s 54±18.9 years, with a range from 20 petent when MMSE scores were used
results on the forensic psychiatrist’s to 83 years. Maximum years of in the analysis.
examination and the HCAT ques- education ranged from 0 to 22 years Further analysis ofthe data found
tionnaire. with a mean±SD of 9.7±4.2. The that competency as measured by the
mean±SD number ofdifferent mcdi- psychiatrist’s assessment was not re-
Results lated signfficantly to either the num-
cations received by each patient in
Interobserver reliability, derived ben of medications the patient had
the 24-hour period before the HCAT
using Pearson’s product-moment was administered was 4.4±2, with a received in the past 24 hours, the
correlation coefficient, was .95 on 16 psychiatric versus medical status of
range from one to nine.
consecutive HCAT questionnaires the patient, the primary organ sys-
The average administration time
(SE=.58, t=11.26, df=14, p<.OO1). tem affected, or the last grade the
was ten minutes for the HCAT and
The coefficient indicated a high de- patient completed in school.
45 minutes for the competency as-
gree of interobserver reliability.
Forty-one subjects agreed to par- sessment conducted by the forensic Discussion and conclusions
ticipate in the study. Twenty-five (61 psychiatrist. The forensic psychia- The Hopkins Competency Assess-
percent) were psychiatric patients, trist found 14 patients (34.1 percent) ment Test is a reliable screening test
and 16 were medical ward patients. not competent to give informed con- for competency that can be adminis-
Twenty-nine patients (71 percent of sent. tered by a nonclinician. The dis-
all subjects) were hospitalized for Mean±SD HCAT scores for the tribution of HCAT scores agreed
treatment of deficits of the central medical and psychiatric patients with a forensic psychiatrist’s opinion
nervous system. The remaining pa- were 5.75±3.2 3 and 5.04±3.38, re- of patients’ clinical competency.
tients were being treated for deficits spectively (t= .51, SE of the differ- The subjects in this sample were

134 February 1992 Vol.43 No.2 Hospital and Community Psychiatry

 every patient for clinical competency
Figure 1 is possible and economically feasible.
Hopkins Competency Assessment Test (HCAT) scores and Mini-Mental Status Ex- her types ofcompetency, such as
amination (MMSE) scores of4l patients judged to be competent or incompetent by a testamentary capacity, could be
forensic psychiatrist tested with screening instruments

similar to the HCAT.

0 Not competent bypsychiatriss Screening tests for competency
examination (N=14)
30 S U U #{149} are especially important in light of
. Competent by psychiathsis . . . : . . : recent court decisions. In Cruzan v.
examination (N=27) S U U Director, Missouri Department of
U

U I Health, the United States Supreme

0 U
,J 0 U U U Court declared that the Constitution
0
20 U provides a competent person “a con-
U stitutionally protected liberty inter-
0 est in refusing unwanted medical
g treatment” (9). The Supreme Court
0 U further stated that “the United States
10
0 Constitution would grant a com-
petent person a constitutionally pro-
g tected right to refuse life saving
hydration and nutrition.”
0 0 The Supreme Court noted, how-
0 I I I I I U I U I I I
ever, that by definition incompetent
0 1 2 3 4 5 6 7 8 9 10
patients are unable to make informed
HCAT score and voluntary decisions regarding
their own health care. The Supreme
Court determined that a state could
patients on a medical and a psychiat- petency assessors. Perhaps criteria establish procedural safeguards to as-
nc ward ofa general hospital. More used by other psychiatrists would be sure that the action of a surrogate de-
than 30 percent of the subjects were associated with a different HCAT cision maker “conforms as best it
judged incompetent to make treat- threshold for competency, and those may to the wishes expressed by the
ment decisions based on a standard used by judges still another thresh- patient while competent.”
clinical competency examination old. Further validation ofthe HCAT The Cruzan case highlights the
even though patients were not select- in comparison with the judgment of importance ofpatients’ making their
ed for the study on the basis of com- other assessors of competency is wishes for medical treatment known
petency. In other settings, such as needed. by writing an advance directive
nursing homes, higher rates of in- Subjects’ scores were distributed before they become unable to make
competency can be expected. over the HCAT range ofO to 10. The medical decisions. Patients must be
The method of assessment was MMSE scores ranged from 0 to 30. competent for the advance directive
similar to that used in the assessment The HCAT allows grading of clinical to be valid. More generally, patients
ofcomprehension ofwnitten docu- competency on a scale from 0 to 10, must be competent to give informed
ments. However, in this case the although in our study the forensic consent for any type ofmedical treat-
document was read aloud to the sub- psychiatrist identified as incom- ment. We propose that the Hopkins
jects, and thus the findings are ap- petent only subjects who scored less Competency Assessment Test is a
plicable to illiterate patients. than 4 on the HCAT. Cutoff points useful tool for rapidly screening large
The results of this study are limit- along a dimension are also used to in- numbers of patients for their com-
ed by the sampling method and by dicate diagnostic categories in assess- petency to make treatment decisions
the validation criteria used. The ment of other clinical conditions, and, more specifically, to write ad-
sample was not randomly selected such as mental retardation or hyper- vance directives.
from the general population, but in- tension.
stead was selected from patients Another interesting aspect of the
hospitalized in an urban teaching results was the failure of the MMSE Acknowledgments
hospital. The study should be repli- to differentiate competent patients
cated in other settings to determine from incompetent patients with This study was supported by grants
from the National Institute of Mental
the generalizability of the results in reasonable sensitivity or specificity.
Health to Drs. Janofsky and Folstein,
other patient groups. This finding suggests that specific
from the National Institutes of Health
The HCAT differs from measures tests of competency are needed in ad- to Dr. Foistein, and from the National
of other conditions because its results dition to standard psychological Institute of Neurological Diseases and
have not yet been compared with measures such as the MMSE. Stroke, the National Institute of Aging,
those made by a wide range of com- Our results suggest that screening and Meridian Healthcare Systems.

Hospital and Community Psychiatry February 1992 Vol.43 No.2 135

 gency Medicine 17:124-126, 1988 of Medicine 302:900-902, 1980
References 4. Taub HA, Baker MT, SturrJF: Informed 7. Baker MR, Taub HA: Readability of in-
consent for research: effects of readability, formed consent forms for research in a
1. Wampler BE, Williams MP: patient age, and education. Journal of the Veterans Administration medical center.
Grammatikifi. San Francisco, Reference
American Geriatrics Society 34:601-606, JAMA 250:2646-2648, 1983
Software, 1988 1986 8. Folstein MF, Folstein SE, McHugh PR:
2. Ley P: Giving information to patients, in 5. Taub HA, Kline GE, Baker MT: The Mini-mental state: a practical method for
Social Psychology and Behavioral Medi- elderly and informed consent: effects of grading the cognitive state of patients for
cine. Edited by Eiser JR. New York, vocabulary level and corrected feedback. the clinician. Journal of Psychiatric Re-
Wiley, 1982 Experimental Aging
Research 7:137- search 12:189-198, 1975
3. Powers RD: Emergency department 146, 1981 9. Cruzan v Director, Missouri Department
patient literacy and the readability of pa- 6. Grundner TM: On the readability of sur- of Health, 497 US, 110 S Ct 2841, 111 L
tient-directed materials. Annals of Emer- gical consent forms. New EnglandJournal Ed 2d 224(1990)

Confidentiality and
the Family as Caregiver
John P. Petrila, J.D., LL.M. Many persons with mental disability about their mentally ill relative and
reside with or are discharged from about the role the family might play
Robert L. Sadoff, M.D.
hospitals to their families. One sur- in patient care-for example, in
vey ofmembers ofNew York’s Alli- monitoring medication and its ef-
Manyfamiiesprovide mentally ill ance for the Mentally Ill found that fects (5-8). Participants in one sur-
relatives with a residence and other 40 percent of the families surveyed vey reported being very concerned
support. Althoughprofessionals in- had mentally ill relatives living with that mental health professionals did
creasingly acknowledge the impor- them (1). Minkoff estimated that not give them information about di-
tance ofthe supportive role families nearly 65 percent of psychiatric pa- agnoses, current treatments, avail-
play, families continue to report tients were discharged from a hospi- ability of community resources, and
that they receive too little informa- tal to their families (2). effective strategies for managing the
tion from professionals about the New and growing recognition of patient’s illness at home (5). Families
patient, particularly when the the importance of developing com- particularly needed information
family acts as caregiver. The au- munity supports has been accom- about medications and side effects,
thors suggest that mental health panied by increased interest among they believed. They stated that it was
professionals’ views about confi- professionals in providing support to often difficult to know whether
dentiality may prevent them from families, principally because the changes in the patient’s condition re-
providing information to families family often functions as the “pni- sulted from reactions to medication
and urge professionals to rethink mary lifelong support system” (3). In or were additional symptoms of ill-
the issue ofconfidentiality and its a recent survey, mental health prac- ness.
application to families acting as titioners strongly agreed that fami- Although attempts to ascertain
caregivers. The authors conclude lies should be incorporated into the perceptions of families and con-
that certain information about a treatment and given a supportive sumers about professional services
patient can-and should-be role (4). Ninety-eight percent of the and attitudes are relatively new, data
shared with families who are in a respondents believed it was very im- from families show that the amount
caregiver role without violating pontant on moderately important for of information provided by profes-
clinical, legal, or ethicalprinciples. families to become educated about sionals is insufficient. In our opinion,
mental illness; 92 percent of the re- families in the role ofcaregiver often
Mr. Petrila is deputy commis- spondents thought it similarly im- receive insufficient information be-
sioner and counsel of the New portant for families to oversee mcdi- cause practitioners believe that legal
York State Office of Mental cation regimens ofpatients living at and ethical principles governing
Health in Albany, 44 Holland home. confidentiality prevent them from
Avenue, Albany, New York At the same time, recent surveys sharing information with families.
12229. Dr. Sadoff is clinical pro- offamilies ofpeople labeled mentally In this paper, we suggest that be-
fessor ofpsychiatry at the Univer- ill suggest that many families believe cause of the critical role families
sity of Pennsylvania. they receive too little information often play in sustaining mentally ill

136 February 1992 Vol. 43 No.2 Hospital and Community Psychiatry