OVERVIEW

Definitions

Patients making medical decisions must provide informed consent. Informed consent includes three components [See Informed Consent chapter]:

Capacity.
Voluntariness: the decision is made without excessive influence from external sources.
Adequate information: the patient receives enough information to make an informed choice about the treatment decision and alternatives.

Medical decision-making capacity (DCM), often referred to as just capacity, refers to the ability to understand and reason through a decision and its consequences.

General Principles

Capacity is a clinical determination, which can be made by any physician, and refers to the ability to make a particular medical decision, such as to pursue a certain treatment, obtain surgery, or leave the hospital against medical advice. This is in contrast to competency, which is a legal determination.

There are four key components to capacity (PUMA):

Preference: the patient must have a clear preference.
Understanding: the patient must understand the decision being made.
Manipulation: the patient must be able to rationally manipulate the key facts in order to come up with a decision.
Appreciation: the patient must appreciate the consequences of the decision and alternatives.

A patient must demonstrate all four of these components in order to have capacity to make a decision.

In completing a capacity assessment, communication should be optimized: hearing aids, written documents, and an interpreter may be needed. Assessing medical knowledge can occur with open-ended questions and providing additional information. The patient should be able to explain how the treatment would impact them, and discuss a rationale for their choice, with their own personal logic and values. It can be helpful to have a member of the primary team accompany psychiatry when seeing the patient for a capacity evaluation, since they may be best placed to communicate risks and benefits.

Psychiatric illness can impair capacity, if the psychiatric symptoms interfere with one or more of the aspects of capacity. For example, if a patient has a delusional belief that his physicians want to harm him, his ability to reason through the decision at hand will be impaired. Simply having a psychiatric illness, however, does not mean a patient lacks capacity to make a medical decision. Additionally, simply disagreeing with a treatment plan does not mean someone lacks capacity.

Psychiatrists who are asked to evaluate capacity of a person making a medical decision should engage with the primary team, to understand the medical recommendation and the risks and benefits of consenting to and refusing the recommendation. It may be helpful to have a member of the primary team present during the capacity evaluation, to ensure that the medical recommendations are being conveyed accurately. In addition, capacity can be determined by any physician, not just psychiatrists. This involvement can educate the primary team about the process of determining capacity so that they feel more confident evaluating capacity of their own patients in the future.

CLINICAL SCENARIOS

Scenario #1: A patient comes to an emergency room complaining of chest pain. His medical work-up points to a myocardial infarction. Before he can receive medical attention, however, he asks to leave because he delusionally believes the hospital staff are aliens trying to attack him. He wants to leave against medical advice (AMA).

This situation is clearly a medical emergency. Furthermore, the patient lacks capacity to leave against medical advice, because his paranoid delusions impair his ability to understand his decision and to rationally manipulate the variables.
He should be kept in the hospital by the least restrictive means necessary, but if necessary, emergency medications and/or restraints should be used to keep him in the hospital for his emergency medical treatment.
When possible, attempts should be made to restore capacity. This is often done via medication and/or education. For example, if a patient lacks capacity to make a decision due to delirium secondary to a urinary tract infection, medical treatment may restore capacity. As another example, a patient who lacks capacity to make a decision due to intellectual disability may simply require education about this decision in order to possess capacity to make this decision.
When a patient lacks capacity and capacity cannot be restored in a timely manner, the next step is identifying a substitute decision-maker. If a medical emergency exists, physicians can provide emergent care without waiting for the consent of a substituted decision-maker. Each state has different guidelines regarding how this substitute decision-maker should be identified. Advance directives may identify surrogate decision-makers. Otherwise, states have guidelines for who to identify as surrogate decision-makers and this includes spouses, parents, and children in various orders of priority. Substitute decision-makers can make decisions based on what the person would have wanted (the “substituted judgment” model) and/or what is in the person’s best interests (the “best interests” model).

Scenario #2: A pregnant woman with a history of schizophrenia requests an abortion. Psychiatry is consulted.

Simply having a psychiatric illness does not mean a person lacks decision-making capacity. The woman’s decision about this highly emotionally charged surgery should be explored and evaluated to see if she has the four elements of capacity, as in any other type of procedure.

Scenario #3: A patient with a history of schizophrenia refuses an elective surgery. The primary team requests that you evaluate the patient’s capacity to refuse the surgery. Before psychiatry has seen the patient, the primary team calls back to say the patient has now agreed to the surgery and you no longer have to see the patient.

Decision-making capacity should be considered whenever patients refuse treatment, but also even sometimes when patients accept recommended medical treatment. A person who lacks capacity to refuse a medical intervention may also lack capacity to accept this same medical intervention. Because the patient’s capacity to refuse the surgery was in question, the patient’s capacity to consent to the surgery should likely be evaluated at this time.

Scenario #4: A patient is scheduled for gastric bypass surgery. He tells you, however, that he is only getting the surgery because his wife threatened to kick him out of the house if he does not.

This patient may lack the ability to provide informed consent. He feels a significant amount of pressure from his wife to get the procedure, which could constitute duress. This may compromise the voluntariness of his decision, which is an element of informed consent.

Scenario #5: A patient with major depressive disorder is hospitalized after attempting to kill himself. The primary team says he needs a blood transfusion to save his life. He refuses the blood transfusion, and he says he is refusing because he wants to die. The primary team also offers him a Band-Aid for a small cut on his forehead. He also refuses the Band-Aid, because the Band-Aid will irritate his skin.

This patient lacks capacity to refuse a blood transfusion, because his rationale is based in his psychiatric illness of depression and his intention to end his life. However, he likely has capacity to refuse a Band-Aid, because the risks of his refusal of this medical recommendation are relatively minor. Capacity is a sliding scale: a person can simultaneously lack capacity to make one complex medical decision and possess capacity to make other simpler decisions.

ADDITIONAL TIPS

Documentation should always include that patients have provided informed consent for their medical decisions. This documentation should include that the risks and benefits of the treatment decision and alternatives were discussed, as well as that the patient understood these risks and benefits and agreed or refused the recommendation. Simply reading a consent form to a patient is not adequate – this process should be a dynamic discussion, where the patient is able to clearly demonstrate understanding of the decision at-hand. If a patient’s capacity is under question, documentation should also include that the patient had or lacked capacity for a decision. If a patient lacks capacity to make a decision, the deficit(s) should be documented.

REFERENCES

Appelbaum PS: Clinical practice. Assessment of patients’ competence to consent to treatment. The New England Journal of Medicine 2007;357(18), 1834–1840. Available at https://www.nejm.org/doi/full/10.1056/NEJMcp074045?casa_token=eKNujCbdyJ4AAAAA:DBxUvpxa3FBiI-HviItIiBU_SDyFsnqkhkheCfq7ZWwoyntoiIMXWE82FJpPtoOJpGUweF6qPL16jvOL
Ehrman SE, Norton KP, Karol DE, Weaver MS, Lockwood B, Latimer A, Scott E, Jones CA, Macauley R. Top ten tips palliative care clinicians should know about medical decision-making capacity assessment. Journal of Palliative Medicine. 2021;24(4):599-604. Available at https://www.ohsu.edu/sites/default/files/2021-04/Ehrman-2021-Top-ten-tips-palliative-care-clinic.pdf
Ross NE, Webster TG, Tastenhoye CA, Hauspurg AK, Foust JE, Gopalan PR, & Friedman SH: Reproductive Decision-Making Capacity in Women With Psychiatric Illness: A Systematic Review. Journal of the Academy of Consultation-Liaison Psychiatry 2022; 63(1), 61–70 available at https://pubmed.ncbi.nlm.nih.gov/34461294/

Overview | Clinical Scenarios | Additional Tips | References

By Nina E. Ross, MD and Susan Hatters-Friedman, MD