Capacity to consent

Capacity to Consent - The Four Pillars

• Communication: Patient must be able to clearly state a choice.
• Understanding: Patient must be able to paraphrase the disclosed information regarding their diagnosis, prognosis, and the risks/benefits of proposed treatments and their alternatives.
• Appreciation: Patient must grasp how this information applies to their own situation and the likely consequences of their decision.
• Reasoning: Patient must be able to weigh the options rationally to reach a conclusion that is consistent with their personal values.

⭐ Capacity is task-specific and can fluctuate over time. It is not a global assessment and must be determined for each specific medical decision.

Assessment Algorithm - The Capacity Check

• Decision-Specific & Dynamic: Capacity is not global; it's assessed for each specific medical decision and can fluctuate over time.
• Clinical Determination: Assessed by a physician; distinct from competence, which is a legal determination made by a judge.

• Understanding: Can the patient paraphrase the risks, benefits, and alternatives?
• Appreciation: Can the patient explain how the information applies to their own situation?
• Reasoning: Can the patient weigh the options logically to reach a decision?

⭐ A psychiatric diagnosis (e.g., schizophrenia, depression) does not automatically mean a patient lacks the capacity to consent.

Lacking Capacity - The Backup Plan

When a patient cannot provide informed consent, decisions fall to a surrogate. The hierarchy for this process is crucial.

• Advance Directives: Legally binding documents outlining patient wishes.

  • Living Will: Specifies desired treatments if terminally ill or in a persistent vegetative state.
  • Healthcare Power of Attorney (PoA) / Proxy: Designates a specific person to make healthcare decisions.

• Surrogate Decision-Maker Hierarchy:

  • If no PoA, the responsibility defaults to next-of-kin in a specific order.
  • 📌 Mnemonic (Typical Order): "Some Spouses Can

High-Yield Points - ⚡ Biggest Takeaways

• Capacity is a clinical determination, while competence is a legal one.
• Core components include the ability to communicate a choice, understand relevant information, appreciate the situation, and use reasoning.
• Capacity is decision-specific and can fluctuate over time.
• A psychiatric diagnosis or involuntary commitment does not automatically mean a lack of capacity.
• If a patient lacks capacity, turn to an advance directive or a surrogate decision-maker.