decision-making capacity; decisional capacity

Introduction

Ability to adequately participate in medical decisions.

Clinical significance

• decisional capacity of the patient to make informed decisions
• 1st step in obtaining informed consent
• dementia & psychiatric illness may interfere with a patient's ability to make informed decisions regarding medical treatment, self-care or issues such as finances
• decisional capacity is decision-specific

Notes

• requirements
  • able to understand relevant information
  • ability to appreciate the situation & its consequences
  • able to rationally manipulate information (reasoning)
  • able to communicate choice & reason(s) for choice
• capacity may be gained or lost, requiring re-evaluation; clinical maneuvers may enhance capacity
  • depression: pharmaceuticals, psychotherapy
  • delirium: treat underlying disorder
  • psychosis: pharmaceuticals
  • cultural mismatch: seek culturally competent communication style
• capacity may be decision-specific, i.e. decisions which entail a greater risk of harm may require stricter standards for capacity
• geriatricians have the ability to determine decision-making capacity in most cases
  • either psychiatry &/or neurology input is sometimes helpful
  • any physician can determine if a patient has decision-making capacity
• minors who are not living independently of parents, not married, & not in the armed forces cannot legally make their own medical decisions
• if a patient is incapable of decision-making capacity
  • a surrogate decision maker is identified
  • the surrogate makes medical decisions for the patient
    • substituted judgement:
      • the decision the surrogate believes the patient would have made
    • best interest:
      • the decision the surrogate believes best for the patient
• competence is a legal term

More general terms

• capacity

More specific terms

• assessment of decisional capacity

Additional terms

• advance directives
• autonomy
• competency
• decision making
• medical ethics