Decision-making capacity is a patient’s ability to understand a proposed intervention, its benefits, risks, and alternatives, including the option of no treatment, and make autonomous decisions regarding their care.
- Decision-making capacity:
- The manifestation of a person’s ability to exercise their autonomy
- A task-specific functional assessment of an individual by a physician
- Dependent on adequate disclosure of information
- Not static: can change within an individual based on the presence or absence of reversible factors (e.g., medication side effects)
- Decision-making capacity is expressed as:
- The ability to provide informed consent
- Informed refusal of treatment
- Underlying principle: “respect for persons,” or the acknowledgment of a patient’s “personhood”
- The precise definition may vary between states and countries.
Components of medical decision-making capacity
There are 4 primary components of medical capacity:
- Communication/expression of choice
|Communication/expression of choice|
Assessment of Capacity
The clinician assesses the 4 elements intuitively through everyday interactions with the patient (e.g., during daily rounds).
Steps for systematic evaluation
The steps below usually take the form of a fluid conversation that doesn’t necessarily follow a strict order. Throughout the conversation, the clinician should be able to determine if the patient fulfills the 4 elements.
- Provide a summary of the patient’s condition. Ask for feedback to gauge the understanding of the patient. Use questions such as, “What is your understanding of your condition?”
- Provide a summary of the available treatment options with their risks and benefits along with the outcomes if no treatment is performed. Ask the patient for feedback using questions such as:
- What are the treatment options available?
- What are the benefits and risks of each option?
- What do you understand will happen if nothing is done?
- Provide a recommendation regarding treatment or how best to proceed. Ask for feedback using questions such as:
- Do you believe this course is right for you?
- Is there any aspect of the course that scares or troubles you?
- Capacity evaluation tools:
- Aid to Capacity Evaluation (ACE)
- Hopkins Competency Assessment Test (HCAT)
- Understanding Treatment Disclosure
- MacArthur Competence Assessment Tool for Treatment
- Assessment of Capacity for Everyday Decisions (ACED)
- Cognitive evaluation tools:
- Mini-Mental State Examination
- Montreal Cognitive Assessment
- Impaired capacity is the lack of decision-making capacity.
- Any illness or treatment that compromises cognition may be associated with reduced capacity.
- The clinician may suspect impaired capacity with the following:
- Inability to express a decision
- Immediate acceptance/refusal of care
- Absence of questions about the course of action
- Excessive/inconsistent reasons for refusing care
- Newly developed dependency
- Hyperactivity, disruptive behavior, or agitation
- Labile emotions or effect
- Diagnoses (e.g., Alzheimer’s disease) are not substitutions for capacity evaluations.
|Fear or discomfort||Expression of fear or discomfort in a clinical setting|
|Neurologic, psychiatric, or developmental conditions|
|Significant cultural or language barriers||Inability to understand the clinical team due to lack of language competency|
Determination of capacity
- The final decision lies with the treating physician.
- All assessments of capacity (e.g., conversations and results using evaluation tools) must be documented in the clinical record.
- If capacity remains uncertain after evaluation with these tools, the next steps include:
- Assessment by a specialized clinician (e.g., psychiatrist)
- In complex or controversial cases, the medical team can seek judicial review to determine competency.
- When in doubt, the determination should typically err on the side of the patient having capacity.
Results determining that a patient has impaired capacity
- Restriction of the patient’s autonomy (prevention of unintended or irreparable harm)
- Patients will require surrogate decision makers:
- Legal power of attorney awarded by the patient
- Closest relative (determined by local laws, typically next of kin)
- Court-appointed health guardians may also be considered in certain jurisdictions.
- If a patient without capacity continues to refuse treatment, court proceedings may be required to give treatment despite objection (in non-urgent cases only).
Competency, or competence, is a legal term defined as the ability of an individual to participate in legal proceedings, which includes their ability to make medical decisions. Determinations of competence are made by a judge and not by a physician.
- The determination of competence is a legally binding determination that establishes whether or not a patient is allowed to make their own medical decisions.
- Competence refers to many areas of a person’s life, including their competency to:
- Make medical decisions
- Stand trial
- Be a parent
- Make a will
- Sign a contract
- Legal competence is a quality that is presumed in every individual.
- Demonstrating a lack of competence requires the presentation of evidence before a judge, who makes the final determination. (Forensic psychiatrists and/or other clinicians may be called upon for testimony.)
- Competence is often used interchangeably with “capacity,” but capacity should only refer to the expression of autonomy that can be determined by a physician on a case-by-case basis.
Components of competence
The components of competence as determined by a judge are listed below. Note the similarity to the 4 components of medical decision-making capacity.
- Ability to understand and process relevant information
- Ability to communicate a choice
- Ability to reason and deliberate
- Ability to hold appropriate values and goals
- Appreciation of one’s circumstances and the possible consequences
- Karlawish, J. (2020). Assessment of decision-making capacity in adults. In Wilterdink, J.L., and Solomon, D. (Eds.), UpToDate. Retrieved June 9, 2021, from https://www.uptodate.com/contents/assessment-of-decision-making-capacity-in-adults
- Barstow, C., Shahan, B., Roberts, M. (2018). Evaluating medical decision-making capacity in practice. American Family Physician, 98(1), 40–46.
- Brendel, R.W., Wei, M.H., Schouten, R., Edersheim, J.G. (2010). An approach to selected legal issues: Confidentiality, mandatory reporting, abuse and neglect, informed consent, capacity decisions, boundary issues, and malpractice claims. The Medical Clinics of North America, 94(6), 1229–1240. https://doi.org/10.1016/j.mcna.2010.08.003
- Have, H., Gordijn, B. (2013). Handbook of global bioethics. Dordrecht: SpringerReference.
- Palmer, B.W., Harmell, A.L. (2016). Assessment of healthcare decision-making capacity. Archives of Clinical Neuropsychology: The Official Journal of the National Academy of Neuropsychologists, 31(6), 530–540. https://doi.org/10.1093/arclin/acw051
- Libby, C., Wojahn, A., Nicolini, J.R., Gillette, G. (2021). Competency and capacity. StatPearls. Treasure Island (FL): StatPearls Publishing. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK532862/
- Buchanan, A. (2004). Mental capacity, legal competence and consent to treatment. Journal of the Royal Society of Medicine, 97(9), 415–420. https://doi.org/10.1258/jrsm.97.9.415