From the Guidelines
The elements of capacity in medical decision-making include understanding, appreciation, reasoning, and communication of choice, as supported by the most recent study 1. A patient demonstrates capacity when they can understand the relevant information about their condition and treatment options, appreciate how this information applies to their situation, reason through the decision-making process by weighing benefits and risks, and clearly communicate their choice. Capacity is decision-specific, meaning a patient may have capacity for simple decisions but not complex ones, as noted in 1 and 1. It's also time-specific and can fluctuate with changes in mental status, medication effects, or disease progression. Healthcare providers should assess capacity using open-ended questions that explore these four elements rather than relying on psychiatric diagnoses or cognitive test scores alone, as recommended in 1. When capacity is questionable, providers should optimize the patient's decision-making ability by addressing reversible factors like pain or medication side effects, simplifying information, and involving trusted family members. If a patient lacks capacity, healthcare decisions typically fall to a surrogate decision-maker who should base choices on the patient's previously expressed wishes or best interests, as discussed in 1 and 1. Some key points to consider when evaluating capacity include:
- Understanding: the patient's ability to comprehend relevant information about their condition and treatment options
- Appreciation: the patient's ability to recognize how this information applies to their situation
- Reasoning: the patient's ability to weigh benefits and risks and make a decision
- Communication of choice: the patient's ability to clearly express their decision
- Decision-specific capacity: the patient's capacity may vary depending on the complexity of the decision
- Time-specific capacity: the patient's capacity may fluctuate over time due to changes in mental status, medication effects, or disease progression.
From the Research
Elements of Capacity
The elements of capacity are crucial in determining a patient's ability to make informed decisions about their healthcare. According to 2, medical decision-making capacity is the ability of a patient to understand the benefits and risks of, and the alternatives to, a proposed treatment or intervention. The key elements of capacity include:
- Understanding of the situation
- Appreciation of the consequences of their decision
- Reasoning in their thought process
- Ability to communicate their wishes
Assessment of Capacity
The assessment of capacity is a critical step in determining a patient's ability to make informed decisions. As stated in 3, capacity is a functional concept, determined by the person's ability to understand, retain, and weigh up information relevant to the decision in order to arrive at a choice, and then to communicate that choice. The assessment of capacity may involve:
- Evaluating the patient's ability to understand and retain information
- Assessing the patient's ability to weigh up information and make a decision
- Evaluating the patient's ability to communicate their decision
Tools and Approaches for Assessing Capacity
There are various tools and approaches available for assessing capacity, including:
- Formal assessment tools, such as those mentioned in 2
- Structured approaches, such as those proposed in 4
- Multidisciplinary approaches, which may involve consultation with psychiatrists or other healthcare professionals, as mentioned in 2
Challenges and Limitations
The assessment of capacity can be challenging, particularly in certain populations, such as those with cognitive impairments. As noted in 5, patients and care partners may not always be accurate in identifying specific cognitive deficits. Additionally, there may be limitations to the use of certain assessment tools or approaches, as discussed in 4.