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Varieties of decisional incapacity: Theory and practice

  • Scott Y. H. Kim (a1)
Summary

Evaluation of decision-making capacity (DMC) for treatment is challenging. Owen et al, in this issue of the Journal, compare the abilities (understanding, appreciation and reasoning) relevant to DMC in medical and psychiatric patients. Here I discuss three key issues their article raises and that are relevant to the direction of future research.

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References
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1 Grisso, T, Appelbaum, PS. Assessing Competence to Consent to Treatment: A Guide for Physicians and Other Health Professionals. Oxford University Press, 1998.
2 Kim, SYH. Evaluation of Capacity to Consent to Treatment and Research. Oxford University Press, 2010.
3 Seyfried, L, Ryan, KA, Kim, SYH. Assessment of decision-making capacity: views and experiences of consultation psychiatrists. Psychosomatics 2013; 54: 115–23.
4 Owen, GS, Szmukler, G, Richardson, G, David, AS, Raymont, V, Freyenhagen, F, et al Decision-making capacity for treatment in psychiatric and medical in-patients: cross-sectional, comparative study. Br J Psychiatry 2013: 203: 461–7.
5 Palmer, BW, Savla, GN. The association of specific neuropsychological deficits with capacity to consent to research or treatment. J Int Neuropsychol Soc 2007; 13: 1047–59.
6 Carpenter, WT Jr, Gold, JM, Lahti, AC, Queern, CA, Conley, RR, Bartko, JJ, et al Decisional capacity for informed consent in schizophrenia research. Arch Gen Psychiatry 2000; 57: 533–8.
7 Berg, JW, Appelbaum, PS, Grisso, T. Constructing competence: formulating standards of legal competence to make medical decisions. Rutgers Law Rev 1996; 48: 345–96.
8 Appelbaum, BC, Appelbaum, PS, Grisso, T. Competence to consent to voluntary psychiatric hospitalization: a test of a standard proposed by APA. Psychiatr Serv 1998; 49: 1193–6.
9 Buchanan, AE, Brock, DW. Deciding for Others: The Ethics of Surrogate Decision Making. Cambridge University Press, 1989.
10 Kim, SYH, Caine, ED, Swan, JG, Appelbaum, PS. Do clinicians follow a risk-sensitive model of capacity determination? An experimental video survey. Psychosomatics 2006; 47: 325–9.
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The British Journal of Psychiatry
  • ISSN: 0007-1250
  • EISSN: 1472-1465
  • URL: /core/journals/the-british-journal-of-psychiatry
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Varieties of decisional incapacity: Theory and practice

  • Scott Y. H. Kim (a1)
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eLetters

Capacity Assessment-Complex and Challenging Indeed

Devender Singh Yadav, Specialty Doctor in Rehabilitation Psychiatry
07 March 2014

The editorial by Scott Y. H. Kim provide valuable insights into the complexities, challenges and ethical dilemmas that clinicians face, when assessing a patient's decision making capacity.

One of the challenges in a busy clinical world is time constraint. Although, capacity assessment is decision and time specific, clinical experience suggests that capacity assessment, done over a period of time, is possibly more reliable (indicating the stability of the patients decision), than, say, if the assessment of capacity is done, once, cross-sectionally.

Also, each dimensional variables of capacity (say for example the dimensional variable of understanding) is a composite effect of various other variables; clinical variables-namely orientation, attention, concentration etc, environmental and socio-demographic variables; how these variables are interlinked, need further exploration in future research. In my view, qualitative research will offer a better understanding of a person's decision making capacity, by placing the patient's decision making capacity in clinical context.

Research has shown that mental incapacity is commonly found in clinical practice (median 29%); that capacity assessment can be done reliably and clinical rather than socio-demographic factors have the greatest impact on likelihood of incapacity [1].

Although capacity is a legal concept, healthcare professionals are frequently asked to assess capacity. Although capacity assessment can be done reliably, clinicians have to consider various clinical variables and hence, sometimes, find assessment of capacity in clinical practice quite challenging. By honing the science and art of capacity assessment from thevery start-foundation years onwards, doctors can build up on valuable experience, which will serve them in the years to come. I highlight this in my article and advice that it is everyone's business to familiarise themselves in the assessment of capacity [2].

References:

[1]: Okai D, Owen G, Mcguire H, Singh S, et al. Mental capacity in psychiatric patients-Systematic review. BJP 2007; 191: 291-297.

[2]: Yadav DS, Torne G. Patient Management; Capacity -Everyone's business. Foundation Years Journal 2011; 5 (10): 19-22.

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Conflict of interest: None declared

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