Who determines a patient's capacity for a surgical procedure with a history of paranoid schizophrenia?

Who Determines Capacity for Surgery in a Patient with Paranoid Schizophrenia

The treating physician (typically the surgeon or anesthesiologist) makes the final decision regarding this patient's capacity to consent to the surgical procedure, and a history of paranoid schizophrenia alone does not preclude capacity—especially in a patient who has lived independently for 10 years. 1, 2

Critical First Principle: Do Not Assume Incapacity Based on Diagnosis

• Mental illness, including paranoid schizophrenia, does not automatically mean a patient lacks capacity for surgical consent. 1, 2
• Even patients detained under mental health legislation should not be assumed incapable of providing valid consent for medical, surgical, or dental treatment. 1, 2
• The fact that this patient has lived independently for 10 years strongly suggests functional capacity and should weigh heavily in the assessment. 2
• Capacity is issue-specific: this patient may have full capacity to consent to surgery even with a psychiatric diagnosis. 1, 2

The Treating Physician's Role and Responsibility

In most instances, it is the person treating the patient (the surgeon, anesthesiologist, or proceduralist) who decides whether the patient has capacity. 1

The treating physician must assess four key abilities: 2

• Understanding: Can the patient comprehend the information about the surgery?
• Retention: Can they retain this information long enough to make a decision?
• Weighing/Reasoning: Can they use and weigh the risks, benefits, and alternatives?
• Communication: Can they communicate their decision?

The assessment should specifically evaluate appreciation—the ability to recognize that the information applies to them personally and understand the consequences of accepting or refusing surgery. 2

If the Patient Has Capacity

• If the assessment demonstrates capacity, the patient provides their own consent—no family involvement is needed and no psychiatric consultation is required. 2
• The patient's decision does not have to be sensible, rational, or well-considered; patients cannot be treated as lacking capacity merely because they make decisions that appear unwise to professionals. 1
• A patient's refusal of treatment, if they have capacity, is legally binding even if refusal could result in death. 1

If the Patient Lacks Capacity

If the treating physician determines the patient lacks capacity for this specific decision, the decision-making authority follows this hierarchy: 3, 2

1. Healthcare proxy/agent (if designated through durable power of attorney or Lasting Power of Attorney) 3
2. Court-appointed guardian/conservator (if one exists) 3
3. Default surrogates according to state law (spouse, adult child, parent, sibling—though not all states have such statutes) 3
4. The treating physician makes the treatment decision based on the patient's best interests when no surrogate exists 3, 2

Best Interests Decision-Making

When the treating physician must decide based on best interests, they must consider: 1, 2

• Medical factors and the nature and prospects of success of the treatment
• The patient's previously expressed values, beliefs, and what their attitude would likely be
• The patient's welfare in the widest sense—not just medical but social and psychological
• Spiritual and religious welfare
• Consultation with family members and others who know the patient (though failure to consult should not compromise emergency care) 1, 2

Documentation Requirements

The treating physician must clearly document: 2

• The grounds for determining capacity or lack thereof
• The specific assessment performed (understanding, retention, reasoning, communication)
• The treatment that will be undertaken
• How this treatment serves the patient's best interests (if capacity is lacking)
• Attempts to consult family or others, if time permitted

Common Pitfalls to Avoid

• Do not assume incapacity based solely on the psychiatric diagnosis—this is the most critical error. 2
• Do not confuse capacity for psychiatric treatment with capacity for surgical consent; these are separate determinations. 2
• Do not wait for family to arrive if surgery is urgent; the physician can proceed based on best interests. 2
• Do not assume that missing a few days of psychiatric medication automatically renders the patient incapable. 2

When to Seek Additional Input

While the treating physician makes the final determination, consider psychiatric consultation if: 1

• The patient's decision appears highly irrational based on persistent misinterpretation of information (though determining incapacity on grounds of irrationality is fraught with difficulty and may require legal advice) 1
• There is uncertainty about whether psychiatric symptoms are interfering with decision-making capacity 1
• The patient's decisional capacity appears to fluctuate 1

However, psychiatric consultation is not required simply because the patient has a psychiatric diagnosis, and should not delay necessary surgery. 1, 2