Dr. Schreiber is Attending Psychiatrist, Department of Psychiatry and Behavioral Sciences, Montefiore Medical Center, New York; Dr. Bourgeois is Clinical Professor, Department of Psychiatry, Texas A & M University Health Science Center, College of Medicine, Bryan, TX; John C, Landry is a Senior Undergraduate, Fordham University, New York;Dr. Schmajuk is Clinical Assistant Professor, Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA; Dr. Erickson is Acting Assistant Professor, University of Washington, Seattle, WA; Dr. Brendel is Assistant Professor of Psychiatry, Harvard Medical School, Boston, MA; and Dr. Cohen is Clinical Professor of Psychiatry, Icahn School of Medicine at Mount Sinai, New York.
Psychiatrists are often consulted to determine whether a patient has the capacity to make medical decisions during an inpatient medical hospitalization. Some of the most challenging decisional capacity consultations are requests to determine if a patient has the capacity to participate in discharge planning. For a patient to demonstrate capacity to participate in discharge planning, the patient should have the capacity for self-care, the ability to cope with illness, and be capable of accessing medical care and treatment once he or she has left the hospital. Frequently such psychiatric consultations are requested when a patient is refusing what the medical team defines as a safe discharge.
In this article, we present some of the complexities of what we propose to call “dispositional capacity,” or the capacity to participate in discharge planning. Inherent in a dispositional capacity determination is an assessment of whether the patient will be able to survive safely and independently in the community following a hospital stay and whether he or she can refuse placement in a chronic care or rehabilitation facility. Basically, the primary medical team is asking the psychiatrist to answer the question: “Can this patient go home?”
Dispositional capacity is a subset of decisional capacity determinations that is distinct from the capacity to give informed consent for or to refuse medical procedures. Although all determinations of decisional capacity are complex and require consideration of the medical, ethical, legal, and psychosocial dimensions of care, most decisional capacity determinations pertain to a single decision as a threshold inquiry of whether the patient can give or withhold informed consent.
While the ability of a patient to participate in his or her own discharge plan is inclusive of elements of a procedure-specific decisional capacity assessment, discharge planning requires other unique dimensions for the clinician to consider. Dispositional capacity determination, in contrast to most other decisional capacity determinations, requires some assessment of a patient’s current functional capacity, prediction of a patient’s future behavior, and ability to self-manage after hospitalization. After discharge from the hospital, the patient must have the ability to make decisions conducive to recovery. Dispositional capacity is therefore a unique subset of decisional capacity that requires an element of prediction.
Review of decisional capacity
Decisional capacity assessments that clinicians perform every day help protect vulnerable individuals from neglect and exploitation, preserve autonomy and self-determination, and help other clinicians and administrators communicate with each other to address complex bioethical and biomedical questions and dilemmas. Decisional capacity has been extensively described elsewhere. These standard capacity evaluations provide a forum for the multidisciplinary hospital team to engage in thoughtful deliberation about how we care for patients in a manner that upholds the highest ethical values of our profession. Myths and facts about decisional capacity are summarized in Table 1.
Capacity questions and their assessments lie on a gradient depending on what is being asked of the patient and the potential risks of their decision. Medical decision-making falls on a spectrum: some choices require more complex thought processes and thus a more sophisticated demonstration of the domains of capacity, including understanding, reasoning, appreciation, and communication of a choice (Figure).
Decisional capacity determinations have medical, psychiatric, functional, and socio-economic components, all of which are involved in the complexity of the patient’s decision-making process. While neurocognitive disorders are the primary drivers of impaired decisional capacity, other psychiatric disorders may also have an adverse impact on decision making. The psychiatrist needs to make a biopsychosocial assessment that includes all elements that may adversely affect decisional capacity. (See Table 2 for examples of how psychiatric disorders can impair decisional capacity).
Understanding dispositional capacity as a distinct concept
On the spectrum of decisional capacity, dispositional capacity appears to be a particularly special circumstance. In the case of decisional capacity, a patient is required to demonstrate adequate cognition as evidenced by an understanding and appreciation of the facts and circumstances and an ability to rationally manipulate information, be capable of intact reality testing relative to the medically relevant information, and sufficient emotional stability to make a consistent choice over time.
Dispositional capacity, on the other hand, is more complicated in that it requires the patient to make multiple present and future decisions that are conducive to good health, and it requires that patients demonstrate adequate functional abilities in the physical and occupational performance areas to survive in the community. Thus, dispositional capacity hinges on many more factors than a focal, discrete choice to accept or reject a medical intervention or diagnostic procedure while in the hospital.
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