Determination of Decisional Capacity

Determination of decisional capacity is a task commonly requested of psychiatrists by medical colleagues in consultation settings and may be required when pursuing guardianship or in other legal contexts, though all physicians regularly complete such assessments as part of their day-to-day clinical work. Decisional capacity is a requirement for the ability to give informed consent for treatment or to refuse it. One commonly used framework for the assessment of decisional capacity encompasses examination of an individual’s abilities across four domains: ability to communicate a choice, factual understanding of the relevant information, appreciation of one’s situation and the possible consequences of the decision, and the ability to rationally manipulate information and reason out treatment options. Several exceptions to informed consent exist, and both the medical community and the legal system have developed models for addressing the care and treatment of individuals unable to give informed consent. For patients who refuse treatment when involuntarily civilly committed, rights-driven and treatment-driven approaches exist that highlight balancing treatment-goals and respect for patient autonomy. Strategies to optimize and support patient decision-making in advance can provide opportunities for patients to have input into their treatment goals during episodes of subsequent incapacity. Psychiatrists can also be asked to assess capacity regarding non-medical decisions, which may require special consideration of the pertinent legal issues associated with the task at hand.