Assessment of Decision-Making Capacity in Patients with Active Hallucinations
Patients who are actively hallucinating and responding to internal stimuli generally lack decision-making capacity due to impairment in their ability to understand, appreciate, reason with, or communicate about medical information. 1
Understanding Capacity Assessment
Capacity is a fundamental prerequisite for valid informed consent and requires evaluation of specific cognitive abilities:
- Capacity assessment must evaluate four key abilities: understanding relevant information, retaining that information, using or weighing information to make decisions, and communicating the decision 1
- Capacity determinations are decision-specific, not global assessments, meaning a patient may have capacity for some decisions but not others 1
- The law presumes all adults have capacity until proven otherwise, regardless of diagnosis 1
Impact of Hallucinations on Capacity
Active hallucinations significantly interfere with the cognitive processes required for capacity:
- Hallucinations create a disturbance in the functioning of the mind that affects the patient's ability to process information accurately 1
- Patients responding to internal stimuli (voices, visions) are unable to properly weigh information as part of the decision-making process due to competing internal perceptions 1
- Command hallucinations particularly compromise capacity when they direct patients toward specific actions or decisions 2
- Patients experiencing hallucinations often have impaired reality testing, which directly impacts their appreciation of their medical condition and treatment options 1
Clinical Assessment Approach
When evaluating capacity in a hallucinating patient:
- Assess if the hallucinations are interfering with any of the four key capacity components: understanding, retention, reasoning, or communication 1
- Determine if the patient maintains insight into the unreal nature of their hallucinations, as preserved insight may suggest some retained decision-making ability 3, 4
- Evaluate if the patient can engage meaningfully in conversation about treatment options despite the presence of hallucinations 1
- Document specific examples of how hallucinations are interfering with the decision-making process 1
Special Considerations
Several factors may complicate capacity assessment in hallucinating patients:
- The presence of hallucinations alone is not automatically disqualifying - the key question is whether they interfere with decision-making abilities 1, 5
- Hallucinations may be caused by various conditions including psychiatric disorders, medication effects, sensory impairments, or medical conditions, which may have different implications for capacity 3, 5
- Capacity fluctuates and may improve with treatment of underlying causes, so reassessment is essential 1
- Patients with Charles Bonnet Syndrome may have visual hallucinations but maintain insight and capacity if their reasoning abilities remain intact 3
Management Implications
When a hallucinating patient lacks capacity:
- Identify and treat the underlying cause of hallucinations when possible 1
- Consider proxy decision-makers according to local laws and regulations 1
- Document the specific reasons why capacity is impaired, focusing on which of the four elements of capacity are compromised 1
- Reassess capacity regularly as hallucinations may resolve or diminish with treatment 1
Ethical Considerations
Balancing patient autonomy with protection from harm requires careful consideration:
- Even when capacity is impaired, attempt to include the patient in discussions to the extent possible 1
- Consider whether the patient had previously expressed wishes about their care when they had capacity 1
- Recognize that inappropriate determination of incapacity can lead to unnecessary restrictions on patient autonomy 1
- Understand that inappropriate determination of capacity can lead to harmful decisions and outcomes 1