Overview of the Capacity evaluation and determining whether a patient has decisional capacity.

1. Capacity
Michael Ingram, MS, MD

2. Capacity vs Competence
• Capacity: A clinical term for an individual’s ability to make an informed
decision about a specific treatment. Must be a specific question that is
being addressed.
• Competence: A legal term determined only by the court. Defined as the
ability to understand and rationally apply knowledge to a decision-making
process. Everyone is assumed competent until proven otherwise.
• Standard or threshold for capacity changes depending on the situation
**Capacity is situation-specific**

3. Threshold for Capacity
• The threshold for capacity will change depending on the risk/benefit
ratio of the patient’s choice.
• Consider the following two scenarios:
1. A 29 year old male admitted to the hospital for syncope is refusing a diagnostic EKG. The
medical team is concerned about his ability to make this decision.
2. A 29 year old male admitted to the hospital for syncope is refusing potentially lifesaving
open heart surgery. The medical team is concerned about his ability to make this decision.
• In scenario 1, the threshold for capacity would be lower compared to
scenario 2. The patient in scenario 1 may not want sticky pads on his chest
but understands what the reason is for the EKG. His level of understanding
may be basic and his rationale for refusing may seem suspect to the
medical team, but him refusing the diagnostic EKG is not really a big deal.
• On the other hand, if the patient in scenario 2 was refusing an invasive
life-saving treatment then he would only be considered capable of doing
so if he could demonstrate a higher level of understanding with sound
reasoning.
**The patient in scenario 2 would be held to a higher standard in
terms of his capacity to refuse because the risk is potentially fatal**

4. Capacity Assessment
Criteria for Decision-Making Capacity:
1. Communicate a choice
▪Pt should be able to indicate a preference
▪Pt’s choice should remain consistent and free from coercion
2. Understand the relevant information
▪Pt should paraphrase info in his/her own words
▪Pt should grasp the meaning of info provided
3. Appreciate the situation and its consequences
▪Pt should acknowledge his/her condition
▪Pt should appreciate reasons for treatment
▪Pt should be able to describe possible outcomes
4. Reason about treatment options
▪Pt should engage in rational conversation
▪Pt should be able to share reason behind choice

5. Capacity Criteria & Sample Questions
• Communicate a choice
• “Have you decided whether to follow your doctor’s recommendation for treatment?”
• “Can you tell me what that decision is? If not, what is making it hard for you to decide?”
• Understand the relevant information
• “Please tell me in your own words what your doctor has told you about the problem with
your health, recommended treatment, p0ssible risks and benefits, alternative treatments,
and risk and benefits of no treatment.”
• Appreciate the situation and its consequences
• “What do you believe is wrong with your health now?”
• “Do you believe that you need some type of treatment?”
• “What is treatment likely to do for you? What makes you believe it will have that effect?”
• “What do you believe will happen if you are not treated?”
• “Why do you think your doctor has recommended this treatment?”
• Reason about treatment options
• “How did you decide to accept/to reject the recommended treatment?”
• “What makes [chosen option] better than [alternative option]?”

6. Documentation of Capacity
• “Based upon my evaluation of this patient, he/she does/does not
express a consistent preference regarding the proposed treatment.
He/She does/does not have a factual understanding of the current
situation as evidenced by [examples]. He/She does/does not appreciate
the risks and benefits of treatment and nontreatment and is
able/unable to rationally manipulate information to make a decision as
evidenced by [examples]. Therefore, in my professional opinion, this
patient has/lacks the capacity to make this medical decision.”
• If capacity is present: “We should respect the patient’s right to make
this decision to…
• If capacity is not present: “A substitute decision maker must be found
for this patient (either health care proxy, Power of Attorney, or guardian
appointed by the court).
• If life threatening emergency: “Treatment may be provided without
consent in a life-threatening emergency where delaying treatment
would compromise the patient’s well-being.”

7. Tips and Hints
• For Triaging Capacity, it is important to ask the following questions
before accepting the consult and seeing the patient…
• Why is the consult being requested?
• Why do you think the patient may lack capacity?
• What is the patient’s medical situation?
• What are the treatment choices faced? Risks and benefits of these choices?
• What has already been communicated to the patient?
• Capacity to make what specific decision?
• If the primary team is not able to articulate a specific question, then
work with them to identify the concerns they have and why they
specifically feel they need psychiatry to be involved. Make every
attempt to include the primary team when doing the assessment so
they can learn how to do an assessment since the most appropriate
assessor of capacity is the treating physician.

8. Tips and Hints
• Common Question: “Patient is trying to leave, but we don’t think he/she
has capacity to make this decision.”
• What to ask:
• Why do you feel he/she lacks capacity?
• What was the reason for hospital admission?
• What was the patient’s mental status on admission?
• What has been communicated to the patient so far?
• What would be the risk if the patient left against medical advice?
• What was the patient’s response when informed about risks?
• In many cases, a capacity assessment is not really the request.
• COMMON: A patient is anxious or worried about a procedure or intervention and
doesn’t have enough information to feel comfortable with the recommendation
• COMMON: A patient had a bad experience in the past and that is why they are
hesitant or refusing.
• COMMON: A patient is withdrawing from drug/alcohol and has intolerable
symptoms which are not being managed adequately (withdrawal symptoms is a
common reason patients request to leave AMA or refuse care).
• Sometimes sitting down with patients and listening to their concerns,
reassuring them, and answering their questions are all they need

9. THE END