From the Guidelines
The best questions to assess a patient's capacity for informed decision-making focus on four key domains: understanding, appreciation, reasoning, and expressing a choice. Begin by asking the patient to explain in their own words what they understand about their medical condition, the proposed treatment, alternatives, and potential risks and benefits, as suggested by 1. For example, "Can you tell me what the doctors have told you about your heart condition?" Next, assess appreciation by determining if the patient recognizes how the information applies to their specific situation: "How do you think this surgery might affect your daily life?" To evaluate reasoning, ask questions that reveal their decision-making process: "What factors are most important to you in making this decision?" and "How did you weigh the risks against the benefits?" Finally, confirm they can clearly express a consistent choice: "Given what we've discussed, what would you like to do about your treatment?"
Additional helpful questions include asking patients to compare options ("Why do you prefer this option over the alternatives?") and exploring their values ("What matters most to you in this situation?"), as recommended by 1. These questions are effective because they comprehensively evaluate cognitive abilities essential for decision-making while respecting patient autonomy. The assessment should be tailored to the complexity of the decision at hand, with more thorough evaluation needed for higher-risk decisions. It's also important to consider that capacity is not all or nothing; it is decision-specific, and loss of decisional capacity may be transient, as noted in 1.
Some key points to consider when assessing patient capacity include:
- Evaluating the patient's ability to understand, appreciate, reason, and express a choice
- Tailoring the assessment to the complexity of the decision at hand
- Considering the patient's values, goals, and preferences
- Being aware that capacity can fluctuate over time and may be influenced by reversible causes such as delirium or medication side effects, as discussed in 1
- Using a multidisciplinary approach, especially in complex cases or when dealing with unbefriended patients, as suggested by 1.
By using these questions and considering these key points, clinicians can effectively assess a patient's capacity for informed decision-making and ensure that their autonomy is respected.
From the Research
Assessing Patient Capacity
To assess a patient's capacity for informed decision-making, several key areas should be evaluated, including:
- Understanding of the situation and relevant information 2, 3, 4
- Appreciation of the consequences of their decision 2, 3, 4
- Reasoning and thought process 2, 3, 4
- Ability to communicate their wishes 2
Evaluation Tools and Methods
Several formal assessment tools are available to help with capacity evaluation, including:
- The MacArthur Competence Assessment Tool-Treatment (MacCAT-T) 3
- Directed clinical interviews 4
- A structured approach to capacity evaluation 2
- A 5-step procedure for assessing competence, which includes recognizing the need for assessment, fully evaluating competence, correlating competence with decision complexity, improving patient competence, and establishing a decision-maker 5
Challenges and Knowledge Gaps
Despite the importance of assessing patient capacity, many clinicians lack confidence and knowledge in this area, with: