Decision-making capacity

Assessing decision-making capacity

Capacity can be assessed by any physician who knows the risks and benefits of a treatment or procedure; don’t need psychiatric specialist c

1. Communicate a Choice:
   • Expresses a clear, stable preference.
   • Frequent, arbitrary vacillation suggests lack of capacity.
2. Understand Relevant Information:
   • Comprehends Dx, proposed Tx, alternative options, and risks/benefits.
   • Assessed via “teach-back” method (e.g., “Can you explain back to me the risks of refusing this surgery?”).
3. Appreciate the Situation & Consequences:
   • Acknowledges their condition and applies the information to their own clinical situation.
   • Recognizes potential outcomes of refusal (e.g., acknowledges that leaving AMA may result in death).
4. Reason Through Options:
   • Patient able to weigh risks & benefits & offer reasons for decision c
   • Decision does not have to align with physician recommendation, but the reasoning cannot be based on active delusions or hallucinations.

Surrogate decision-making

• Trigger: Activated only when a licensed physician assesses that the pt lacks decision-making capacity for a specific clinical choice.
• Priority Hierarchy:
  1. Competent Patient: Direct autonomous choice overrides all prior documents, surrogates, and family opinions.
  2. Advance Directives (Living Will): Explicit written directives regarding interventions (e.g., DNR/DNI, intubation, artificial nutrition).
  3. Designated Healthcare Proxy / DPOA: Legally appointed agent; supersedes all default family members (including spouse).
  4. Default Next-of-Kin (Statutory Hierarchy): Spouse → Adult Children (equal authority) → Parents → Adult Siblings → Other relatives/close friends.
  5. Unrepresented Patient: Implied consent (emergency) or Hospital Ethics Committee / court-appointed guardian (non-emergent).
• Standards of Decision-Making:
  • Substituted Judgment (1st-line / Preferred): Surrogate must decide based on what the pt would have wanted, using the pt’s known values, religious beliefs, and prior verbal statements. c
  • Best Interests (2nd-line / Default): Used only when pt values are entirely unknown; decides based on what a reasonable person would choose by weighing objective risks and benefits.
• High-Yield Board Scenarios & Management:
  • DPOA vs. Living Will: Follow the Living Will. A written advance directive takes precedence over a surrogate’s conflicting personal preferences.
  • Equal-Rank Surrogates Disagree (e.g., siblings): Facilitate a family meeting focused on pt’s values (substituted judgment); consult the Ethics Committee if deadlocked (do not take a majority vote; do not choose one sibling).
  • Emergency with No Surrogate: Provide life-saving care immediately under implied consent; do not delay treatment to locate next-of-kin or consult ethics.
  • Parental Refusal of Life-Saving Care for a Minor (e.g., blood transfusion): Administer life-saving therapy immediately; parental authority does not permit martyrdom of a child.
  • Non-Emergent Parental Refusal: Obtain a court order or contact Child Protective Services (CPS).
  • Confidential Care for Minors (No Parental Consent Needed): Contraception/pregnancy care, STIs, substance use disorders, and outpatient mental health.