Old Blog Post on Decisional Capacity Assessment

I just found a blog post I wrote about assessing decisional capacity. It’s over 13 years old and you can tell I was a little frustrated when I wrote it. It was back in the days when consulting psychiatrists were called psychosomatic medicine specialists. Here’s to another blast from the past.

Blog from 2011: Thoughts on Assessment of Medical Decision-Making Capacity

Listen very carefully to what I’m about to say. A patient’s ability to make decisions about her medical or surgical treatment does not depend on knowing her surgeon’s name.

Let me put it differently. Simply because you can recall your surgeon’s name doesn’t mean you have the decisional capacity to give or not give informed consent to have surgery.

If that’s too obvious to most of you, then maybe I can stop worrying that it isn’t to so many doctors, who sometimes misunderstand or are simply unaware of the basic principles of assessing decisional capacity regarding medical treatment. Believe it or not, some physicians actually believe the above is part of an adequate decisional capacity assessment.

Psychosomaticists are frequently called to assess decisional capacity to participate in the informed consent discussions that are such an important part of the doctor-patient relationship today.  Many non-psychiatric doctors simply don’t feel confident that they can do it themselves. And when they try, their description of the process often indicates an alarming deficit in their medical school education about this basic skill.

In order to give informed consent, you need to have enough information from your doctor, be able to voluntarily make a decision without undue pressure from others (including your doctors), and be competent to decide. Exceptions to obtaining informed consent include but are not limited to “incompetence” (the inability to decide) and medical emergencies.

In a nutshell, the basic elements of assessing decisional capacity are:

1. Any physician can do it; a psychiatric consultation is not obligatory though it may be helpful in difficult cases in which delirium or other mental illness may be substantially interfering with decision-making.
2. The patient’s ability to understand her medical condition and the risks and benefits of the main and alternative medical interventions proposed as treatment.
3. The patient’s appreciation of the nature of her medical condition and the potential consequences of the treatment options or no treatment in the context of her values and wishes.
4. The patient’s ability to reason through her choices regarding treatment.
5. The patient’s ability to express a choice.

Notice that nowhere in the above list is recall of the surgeon’s name even mentioned. Remembering your surgeon’s name may be flattering but it’s not essential to the assessment of decisional capacity.

There are several reasons to assess decisional capacity including but not limited to an abrupt change in the patient’s mental status. This is commonly caused by delirium, which by definition is an abrupt change in affect, cognition, and behavior that fluctuates and is by definition related to medical causes.

Any physician can conduct a decisional capacity evaluation, yet a psychiatric evaluation is frequently requested.  The reason for that may arise from the assumption that the Psychosomaticist is a sort of “informed consent technician”[1]:

1. “Efficiency model” scenario
   1. Incompetence is presumed.
   1. Psychiatric consultant is expected to remove legal barriers expeditiously to obtain a surrogate decision maker.
2. “Pseudoconsultation” scenario
   1. Consultation requestor lacks the patience, interest, or time to do an assessment.
3. “Persuasion” scenario
   1. Psychiatric consultant is expected to persuade the patient to reverse his refusal of needed treatment.
4. “Protection” scenario
   1. Psychiatric consultant is expected to provide documentation to protect against potential litigation.
5. “Punishment” scenario
   1. Stigma associated with psychiatric evaluation is used unconsciously to punish treatment refusal behavior.

In all fairness, psychiatrists are sometimes just as guilty of this buck-passing; for example, when we request a cardiology consultation to “medically clear” a patient for electroconvulsive therapy to treat life-threatening depression.

In an ideal world, a decisional capacity evaluation would be requested in and accepted in “the true spirit of dialogue as the result of a genuine evaluation of the patient’s mental state as a whole”[1].

We don’t live in an ideal world. So when a doctor is truly stuck and needs help with decisional capacity evaluations, she can confidently call a practical Psychosomaticist in the true spirit of collaboration as a result of the genuine appreciation of the importance of the patient’s medical and psychiatric care as a whole.

1.            Zaubler, T.S., M. Viederman, and J.J. Fins, Ethical, legal, and psychiatric issues in capacity, competency, and informed consent: an annotated bibliography. Gen Hosp Psychiatry, 1996. 18(3): p. 155-72.