Decision-Making Capacity

A patient is capable of making a decision when his/her ability to make a decision is adequate to the task at hand.

Decisional capacity is not an all or nothing thing. A patient has decisional capacity if he/she is capable of giving informed consent or refusal for the proposed intervention. The informed consent process has three main elements, information, understanding and voluntary choice. These elements are the basis for the main standards for decisional capacity.

General questions for assessing a patient’s decisional capacity:

1. Can the patient make and communicate a choice?
2. Does the patient understand the information that is relevant to the decision at hand?
3. Can the patient recognize how this information applies to his/her own situation?
4. Is the patient’s decision consistent with his/her own values and goals?
5. Is the decision the result of a delusion or distorted view of reality?
6. What are the patient’s reasons for the decision? Is the reasoning process logical? (Is the patient’s rationale for the decision reflective, clear, and consistent with the patient’s goals and decision?)

There are many things that can affect a patient’s decisional capacity either negatively or positively. Health care professionals should make a reasonable effort to maximize a patient’s decisional capacity.

Some ways you can enhance decisional capacity:

• adjust timing, treatment and medication regimens so assessment and discussions occur when the patient is most likely to be alert and oriented.
• try to reduce fear, anxiety, anger, etc. which may interfere with good decision making
• promote trust and avoid coercion
• present information in clearly, simply, repeatedly and in small amounts over time
• consider whether the presence of family or friends might comfort and help the patient understand and focus on the important information
• when in doubt about the ability to understand English, use an unbiased translator
• for those who can’t speak, adjust the conversation to use yes/no questions, writing pads, or letter boards
• written information is helpful, but don’t assume a patient can read

A psychiatric consult can be helpful. But someone who knows the patient for a longer period of time may have a better understanding of the patient’s base-line capacity and what might enhance capacity. The attending physician is ultimately responsible for determining whether a patient lacks decisional capacity.

If a patient lacks capacity, a surrogate should be identified who will be able to make decisions based on the patient’s values (if possible).

Competency is a legal determination and implies a more permanent loss of capacity. One should only consult the courts as a last resort.

References:

Lo, B. Resolving Ethical Dilemmas: A Guide for Clinicians, 2^nd Ed. Lippincott, Williams & Wilkins (Philadelphia: 2000).

Drane, J. “The Many Faces of Competency,” Hastings Center Report 15:2 (April 1985).

Grisso, T. & Appelbaum, P. Assessing Competence to Consent to Treatment, Oxford Univ. Press (New York:1998)