Some of the most challenging decisional capacity consultations are requests to determine if a patient has the capacity to participate in discharge planning.
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.
Seen in this light, dispositional capacity to refuse a safe discharge requires a higher bar of understanding and self-awareness by the patient. A patient may have the decisional capacity to give informed consent for an extremity amputation, but may not have dispositional capacity or the capacity to care for himself or herself at home after recovering from the surgery. Conversely, a patient may lack decisional capacity to refuse a risky CNS tumor resection but nonetheless have dispositional capacity to return home with family supports. Each type of decision requires a full psychiatric assessment, and “one size does not fit all.”
Special elements of dispositional capacity
Dispositional capacity determination requires a multidimensional biopsychosocial approach to the patient. This approach, while important in all capacity determinations, is even more critically salient in determination of dispositional capacity, and includes an appreciation of the biological, psychological, and social obstacles that must be overcome to maintain health, safety, and access to care in the community. A dispositional capacity assessment requires an evaluation of:
• Understanding of the medical illness
• Obstacles to understanding (eg, language, socio-cultural barriers, neurocognitive disorders, substance use disorders, other psychiatric disorders)
• Ability to perform activities of daily living (ADLs) and instrumental activities of daily living (iADLs) or to accept assistance with these needs
• Social factors (family dynamics, housing, economics, and broader social supports)
• Access to and navigation through the health care system
To begin, a clinician must first assess a patient’s understanding of his or her ongoing medical problems and what specific interventions are needed upon discharge (eg, physical or occupational therapy, follow-up medical appointments). Subsequently, the clinician must assess cognitive difficulties that are interfering with the patient’s understanding of the illness and medical care needs.
Case Vignette #1
Mr. A is an 85-year-old with a past medical history of hypertension, diabetes, and coronary artery disease who presents after a fall in his apartment. It was hours before his daughter found him on the bathroom floor. Upon admission to the hospital, Mr. A was dehydrated with associated rhabdomyolysis, acute kidney injury, and hypernatremia; he was treated with IV hydration. He sustained a hip fracture but refused the recommended hip replacement. The consulting psychiatrist diagnosed delirium, possibly superimposed on a major neurocognitive disorder (dementia), and prescribed PRN haloperidol for agitation. His daughter provided informed consent for the surgery.
After surgery, the orthopedic team recommended discharge to a subacute rehabilitation facility (SAR) to assist with his post-operative recovery. Mr. A was adamant that he be discharged home. The psychiatrist was called in to assess dispositional capacity. Mr. A believed he would be fine at home because he’s a “strong man” and “I can take care of myself.” He seemed unaware of any risks to returning home and couldn’t explain how he would prepare his food or attend to his grooming. He scored poorly on the Montreal Cognitive Assessment with a score of 16. An occupational therapy evaluation demonstrated a failing score on the KELS. The psychiatrist found that Mr. A lacked dispositional capacity; after much encouragement from his daughter, Mr. A agreed to a temporary SAR stay to regain his mobility.
Functional assessments to clarify a patient’s limitations with daily activities, including iADLs and ADLs, can further elucidate areas of concern. Collaboration with a team of experts is most relevant in dispositional capacity determinations. Specifically, an occupational therapist can provide a Kohlman Evaluation of Living Skills (KELS) or other similar assessment of self-management abilities that can be selected based on patient-specific characteristics. KELS or similar instruments can provide comprehensive evidence of cognitive skills involved in self-management. Input from physical, occupational, and speech and language therapists can assist the psychiatrist in better understanding the patient’s current level of functioning.
Social workers can arrange access to community programs such as home health aides, visiting nurses, physical and occupational therapy, companions for persons who are visually impaired, transportation to medical appointments, prepared food delivery for meals, and panic buttons, all of which can make home a safer place for elderly patients with cognitive impairment. A patient who is unable to adequately perform iADLs and ADLs may still be safely discharged if a family member, friend, or a home health aide is available to assist with shopping, cleaning, food preparation, and transportation to medical appointments. Social workers can also help identify untapped resources such as family, friends, or members of the patient’s religious faith to help the patient after discharge.
Sliding scale of dispositional capacity
There are many types of medical decisions, and each of these may require greater or lesser levels of understanding, cognition, and emotional function. For example, there are simple versus complex surgical and other procedures for which a patient might need to consent. To appoint a surrogate decision-maker, the necessary decisional capacity level is an understanding of the role of the surrogate and an ability to consistently name that person with little focus on the patient’s awareness of the strengths or weaknesses of each proposed surrogate. This applies as long as there are no concerns about the appropriateness of the surrogate and it is not a risky decision.
To accept a recommended medical procedure, the necessary capacity level is a consideration of the risks of failure and benefits of success from the procedure that is being recommended by the treating physician. To reject a recommended procedure, the necessary decisional capacity level involves knowledge of the risks of recovery without the procedure.
As with the varieties of risk among the different kinds of medical decisions, there is a spectrum of different levels of dispositional capacity that a patient might need. Overall, we can speculate that because dispositional capacity requires a greater degree of cognition for consistent and ongoing self-management, patients who “just barely” satisfy the functional criteria of valid decisional capacity for a routine medical procedure may nonetheless lack dispositional capacity.
Patients with poor cognitive function who lack capacity to refuse a medical or surgical procedure, are also likely to lack dispositional capacity. Conversely, a patient with a stable home, caring family members, good access to clinical follow-up, and adequate financial resources may be better able to manage post-hospital care at a lower level of cognitive and psychiatric function than a patient without ready access to these resources. Patients who are paranoid, either from a neurocognitive disorder or a psychotic disorder, may not fare as well in the community because they will not allow family or homecare agencies access to their home to provide needed assistance.
Case Vignette #2
Ms B is a 90-year-old widow with hypothyroidism, schizophrenia, and mild neurocognitive disorder. She lives in her own home with the support of a home health aide and assistance from 2 sons. She has chronic paranoia and life-long beliefs that the FBI is spying on her and targeting her children. Ms B’s pharmacy packages risperidone in blister packs and her aid reminds her to take the medication.
She presents to the hospital with her son for abdominal pain and is found to have a perforated duodenal ulcer. Although she believes the FBI has caused the ulcer, she agrees to all recommended treatments and her decisional capacity is not questioned. Her hospital course is complicated by sepsis and delirium. She requires PRN risperidone, in addition to her standing risperidone, which is recommended by the consulting psychiatrist.
When it is time for discharge, the medical team recommends SAR. However, Ms B wants to go home because she believes that the FBI will have better access to her at SAR. The psychiatrist is called in for an assessment of dispositional capacity. Ms B explains her reasoning to the psychiatrist and acknowledges that others might choose differently. She agrees to resume her homecare services, and her sons agree to check on her daily.
Ms B scores in the mildly impaired range on the Montreal Cognitive Assessment with a score of 18. She has prominent delusions but her family and psychiatrist confirm that she is at her baseline; she has no homicidal or suicidal thinking. She is found to have dispositional capacity and is safely discharged home with resumption of her community supports.
Dispositional capacity is a specific subset of decisional capacity that addresses a patient’s ability to accept or reject a safe discharge plan. Psychiatrists are often called upon to assess dispositional capacity when a patient is refusing the recommended discharge plan, sometimes in concert with decisional capacity for informed consent for a medical procedure, and sometimes solely in the discharge context.
Assessment of dispositional capacity, framed as a distinct subtype of decisional capacity, includes a comprehensive diagnostic psychiatric evaluation as well as targeted evaluations by occupational and physical therapy staff and social workers to provide the optimal interdisciplinary assessment of the patient. This complete appraisal, tailored to the patient’s specific circumstances, addresses the patient’s safety and honors the 4 principles of biomedical ethics, specifically balancing patient autonomy against physician beneficence, nonmaleficence, and justice. Mastery of the dispositional capacity assessment is an essential core skill for consultation-liaison psychiatrists who are crucial members of the health care team.
Acknowledgement-The authors acknowledge the Academy of Consultation-Liaison Psychiatry for helping to bring this article to fruition. The Academy is the professional home for psychiatrists providing collaborative care bridging physical and mental health. Over 1200 members offer psychiatric treatment in general medical hospitals, primary care, and outpatient medical settings for patients with comorbid medical conditions.
1. Ganzini L, Volicer L, Nelson WA, et al. Ten myths about decision-making capacity. J Am Dir Assoc. 2005;6(Suppl 3):S100-104.