Decisional capacity

IN THIS ISSUE: Hackett  |  Decisional capacity  |  Posters  |  Psychotropics 

Updated Guidelines on Decisional Capacity

A group of ACLP members—who sit on the American Psychiatric Association’s Council on Consultation-Liaison Psychiatry—have written a paper, Resource Document on Decisional Capacity Assessments in Consultation-Liaison Psychiatry, now published on the APA website.

James Bourgeois, OD, MD, FACLP; Maria Tiamson-Kassab, MD, FACLP; Kathleen Sheehan, MD; Diana Robinson, MD; and Mira Zein, MD, MPH, set out to provide all psychiatrists with a common framework to guide them when periodically functioning in a C-L Psychiatry role, and to assist them in completing decisional capacity (DC) assessments in an evidence-based, standard process.

The paper outlines a seven-item recommended approach to DC assessments (see panel below) and cites recent research literature.

ACLP News has been talking with one of the work group.


James Bourgeois, OD, MD, FACLP
James Bourgeois, OD, MD, FACLP


“Standardized training is not often available—yet we are called upon to advocate for and exercise an ethical method in this complex, ever-changing socio-political arena”

“The C-L psychiatrist is often asked to lend expertise in the assessment of decisional capacity, particularly as it relates to treatment refusals, resuscitation (‘code’) status decisions, and end-of-life medical management decisions,” says Dr.Bourgeois.



Familiarity with the principles of biomedical ethics, together with changing socio-political and legal trends impacting DNR (do not resuscitate) and similar orders, inform decisional capacity assessments, he says.

C-L psychiatrists need to be capable of advocating and exercising ethical positions. Yet, formal training and supervised clinical experience in this complex arena is not often readily available in psychiatry residency training programs.

The APA resource document provides evidence-based guidance in C-L Psychiatry settings covering:

Decisional capacity questions

Steps through the process are defined, starting with determining the type of decisional capacity (DC) question.

For some DC types, such as informed consent, a full description of the proposed intervention and its risks, benefits, side-effects, and alternatives is advocated.

“Defining the specific question is critical because the patient may have intact DC in some areas, but not others,” says Dr. Bourgeois.


The patient may have intact decisional capacity in some areas, but not others

—Dr. Bourgeois


Informed consent
For informed consent decisions, the guidelines recommend what information should be disclosed, how much the patient providing consent should understand, and how explicit consent should be.

Strategies and tools are recommended to enhance a patient’s understanding—simplified written information, extended discussion, audio-visual and multimedia programs and test/feedback techniques. Particular attention is advocated for patients with limited literacy and/or limited English proficiency.

DC should be assessed through a standardized psychiatric interview and neurocognitive disorder workup, say the guidelines:

“Assumptions should not be made that all patients with psychiatric illnesses, including neurocognitive disorders, necessarily lack DC, nor that patients on a psychiatric commitment order necessarily lack DC,” says Dr. Bourgeois.

DC-specific instruments
Research identifies poor inter-rater reliability among clinicians about DC—and so DC-specific instruments could be used to supplement (not replace) the clinical interview. Whereas the standards of such instruments vary, some assess all four of the classic DC domains:

Some can be modified to include data about a patient’s specific clinical situation.

Dispositional capacity
Assessment of dispositional capacity (the concept of caring for oneself post discharge) necessitates evaluation beyond the psychiatric evaluation and covers, for example, sensory capacities, mobility, and ability to perform tasks of daily living. Assessments should routinely include input from occupational therapy and social work colleagues.

“C-L psychiatrists should not limit their consultations to a sole focus on the decisional capacity question(s),” says Dr. Bourgeois. “Rather, we should conduct comprehensive assessments for the various psychiatric illnesses (e.g., neurocognitive disorder, psychotic disorder, substance use disorder) as well as the various purely social variables (sometimes in the absence of explicit psychiatric illness).”


Assumptions should not be made that all patients with psychiatric illnesses lack decisional capacity

—Dr. Bourgeois


Fluctuating DC
Furthermore, repeated assessments need to be made with patients at high risk of fluctuating decisional capacity. “Fluctuating DC is particularly likely when delirium occurs superimposed on a pre-existing major neurocognitive disorder,” says Dr. Bourgeois. “A specific challenge encountered in delirium cases is the patient who experiences ‘lucid intervals’ during an episode of delirium with fluctuating cognitive status. During such lucid intervals, the patient may demonstrate intact DC. This represents a clinical and ethical challenge, in that the patient may later (during a period of greater cognitive impairment) not recall an earlier informed consent discussion during which he/she appeared to have been able to capably manage.”

Challenges over the use of SDMs (surrogate decision-makers) in determining a patient’s decisional capacity are also explored in the guidelines, not least that, to date, there is no clearly accepted methodology to assess SDMs, says Dr. Bourgeois.

The full paper, Resource Document on Decisional Capacity Assessments in Consultation-Liaison Psychiatry, is available here.

Document Summary Recommendations

  • Ascertain the type of capacity concern (i.e., informed consent re interventions vs global treatment refusal vs AMA (DC) vs capacity for independent function (dispositional capacity); many patients may need evaluation for both types of decisions simultaneously, depending on the complexity of the case
  • Perform a standardized consultation-liaison psychiatry interview, including a neurocognitive disorders workup (e.g., standard cognitive rating scale, relevant laboratory studies to elucidate reversible causes of neurocognitive disorders, consideration of neuroimaging). To quantitate depressive symptoms, use a Hamilton Depression Rating Scale or other standardized rating scales
  • Formulate a psychiatric diagnosis(es) (or “no psychiatric illness” if none is found), with diagnostic summary and proposed additional assessment (e.g., neuroimaging, laboratory) and recommended clinical intervention(s)
  • For informed consent for medical/surgical procedure(s), have the patient provide a full description of the proposed procedure and its risks/benefits/side effects. If there is clinical evidence of cognitive impairment, modify consent process to facilitate patient performance
  • Separately address the four Appelbaum and Grisso factors pertinent to the proposed intervention (Understanding, Appreciation, Rationality, Communication of Choice for or against intervention) to ascertain which one(s) are impaired in the finding of impaired decisional capacity
  • Consider DC-specific instruments, if the clinician is experienced in their use and they are readily available
  • For dispositional capacity/social function assessments, consider supplementing standard consultation-liaison psychiatry interview with in vivo assessment using OT/other supplemental assessments
  • Provide a concise summary of case diagnosis(es) and clinical formulation
  • Place the decisional capacity status in a context specific to the question(s) at hand
  • Comment on whether treatment could change decisional capacity findings
  • Describe “differential capacity” findings (e.g., choose a substitute decision maker even if not able to consent/refuse surgery per se).


« « All 2019 ACLP News « September 2019 ACLP News