Medical Decision-Making Capacity

Laura Artim, reviewed by Jonathan Smith and Daniel Daunis

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Background

• Capacity is a patient’s ability to make a specific medical decision at a specific point in time and can be assessed by any physician

• Capacity is fluid and may change with the patient’s mental status and or medical state. A person may have capacity to make one decision and not another

• Competency: “global decision-making capacity” or ability to make financial decisions, etc are legal determinations made by a judge

Evaluation

• Four key components

  • Consistent choice: patient must clearly indicate a consistent choice

    • “Have you decided whether to follow the recommendation for the treatment?”

    • “Can you tell me what your decision is?”

  • Understand: Patient must grasp the fundamental meaning of the information communicated by the medical team

    • “Please tell me in your own words what you were told about:

    • The problem with (1) your health now and (2) the recommended treatment

    • The risks/benefits of (3) treatment, (4) alternative treatments and (5) no treatment”

  • Appreciate: patient must appreciate the medical condition and likely consequences of treatment options

    • “What is treatment likely to do for you?”

    • “What do you believe will happen if you’re not treated”

    • “Why do you think this treatment was recommended?”

  • Manipulate: patient must rationally manipulate relevant information

    • “What makes the chosen option better than the alternative?”

    • “How did you decide to accept or reject the recommended treatment?”

Management

• If the patient does not have medical decision-making capacity:

  • Identify and remedy cause of impairment if possible (if decision is non-urgent)

  • Identify surrogate decision maker

• Documenting medical decision-making capacity:

  • Use a dot phrase .Capacity that lists the four components and document your thought process citing evidence from your interview