Evaluations of decisional capacity are among the most common—and the most complex—psychiatric consultations. Determination of decisional capacity is fraught with myths that may mislead all physicians. These misunderstandings present clinical pitfalls that can result in serious medical, ethical, legal, and psychosocial challenges. Conversely, the ability to conduct a decision-making capacity assessment with knowledge, skill, empathy, and wisdom is a duty and service of high ethical value and significance. Decisional capacity assessments that psychosomatic medicine psychiatrists perform every day help protect vulnerable individuals from neglect and exploitation, preserve autonomy and self-determination, and help other clinicians and administrators solve complex bioethical and biomedical dilemmas.
These evaluations provide a forum for the entire health care community and its stakeholders to engage in thoughtful deliberations that inform policy development that upholds the highest ethical values of our profession and society regarding medical care and research.
This article will focus on capacity to participate in medical decisions rather than research, but there is considerable overlap in the principles and procedures presented.
Facts and myths about decision-making capacity
One of the most important reasons to tease apart the facts from the myths is that so many of the individuals for whom capacity assessments are requested have psychiatric disorders, such as schizophrenia and dementia (Table 1). The majority of patients with schizophrenia and most patients with mild to moderate dementia are—with psychiatric care, assistance, patience, kindness, and time—able to make many basic medical and dispositional decisions.1
Findings from a recent study of over 2500 patients indicate that, contrary to the hypothesis of the research, it was not psychosis that led to incapacity but rather cognitive impairment and substance use.2 The exception is when the psychopathology directly interferes with the patient’s decision-making process as in the frequently encountered case examples in Table 2.
The presumption that patients with psychopathology do not have decisional capacity is often grounded in an even more profound misunderstanding of decision-making capacity as monolithic: that decisional incapacity in one area, such as finances, precludes capacity in all areas. Most of us are able to make better decisions in some areas of our lives than in others. Similarly, it is often assumed that capacity is static, when it is really a dynamic, granular ability that is better at some times and worse at others.
Delirium is among the most frequently encountered, yet often unrecognized, conditions that impair the capacity of patients to make decisions in the settings of emergency departments as well as medical, surgical, and intensive care units.3 Because of the intrinsically fluctuating nature of delirium, which typically worsens toward evening, and our obligation to offer the patient an optimal opportunity to perform well on the assessment, it is often best to conduct capacity evaluations in the morning—especially for patients with or at risk for delirium.
Yet this variability is also a positive: it means that we can enhance a patient’s ability through basic interventions we know well as psychiatrists, such as normalizing the sleep-wake cycle; treating anxiety, depression, and psychosis; and providing supportive psychotherapy. Both pharmacological and psychological treatments as well as a variety of cultural adjustments, such as having a trained interpreter and educational modalities (eg, audiovisuals, social supports involving family members), have been shown to improve the ability of patients with physical and psychiatric illnesses to optimize their decisional capacity. Ethically, it is our obligation to try these interventions so that we give the patient the “best chance” to do as well as possible and to assess the patient at the point of his or her highest capacity.
An essential aspect of this “best chance” is that the psychiatrist must define the object of the capacity request. The first thing we teach psychiatric residents who respond to a consultation request for capacity determination is to discuss with the requesting clinician, “Just exactly what is the question?” This helps to begin a dialogue and to elicit the latent as well as the manifest content of the consultation question. A study examined 100 consecutive consultations for capacity evaluations submitted to a psychosomatic medicine service at an academic medical center. The results of this study showed that approximately the same number of consultations were received for the capacity to consent to a treatment or procedure, the capacity to refuse a treatment or procedure, the capacity to leave the hospital against medical advice, and the capacity to accept or reject a discharge plan (Table 3).4
Dr. Geppert is Professor of Psychiatry and Director of Ethics Education, University of New Mexico School of Medicine; and Chief, Consultation Psychiatry and Ethics, New Mexico VA Health Care System, Albuquerque, NM. Dr. Cohen is Clinical Professor of Psychiatry, Icahn School of Medicine at Mount Sinai, New York. Dr. Bourgeois is Clinical Professor and Vice Chair of Clinical Affairs, department of psychiatry, Langley Porter Psychiatric Institute, University of California, San Francisco. Dr. Peterson is Associate Professor in Psychiatry, University of Wisconsin School of Medicine and Public Health and Director of Hospital Psychiatric Services, University Hospital, Madison, WI. The authors report no conflicts of interest concerning the subject matter of this article.
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