In the 1914 case of Schloendorff versus the Society of New York Hospital, Justice Cardozo wrote, “every human being of adult years and sound mind has a right to determine what shall be done with his own body.” Determining a "sound mind," or decision making capacity is something that we do often in the emergency department. This makes many providers uncomfortable because it gives patients the ability to refuse our recommendations. This POTD is going to go over what defines capacity and how we can assess it.
Capacity refers to the ability of a person to utilize information about their illness and proposed treatments to make a choice that aligns with their values. Determining capacity is often a clinical judgment typically made by a physician, whereas competence is a legal state determined by a judge. Assessing for capacity allows us to act in our patient’s best interest while respecting their autonomy.
You can assess for capacity by determining if the patient has the ability to: 1. Communicate 2. Understand the information 3. Understand the situation 4. Manipulate the information presented and make a logical decision.
These points can be ascertained by asking the patient to recount their story, your recommendations, state what they do or don't want, and back their decision up with logic.
It is important to note that capacity is defined around a specific medical decision; you should assess capacity with each new intervention or treatment proposed. In addition, capacity can be transient and exist along a continuum. So before you call up psych to help determine if your patient can refuse dialysis, go through these 4 points and see if you can determine decision making capacity yourself.
Thanks for reading!
Ariella
References:
https://www.emrap.org/episode/november2014/decisionmaking
https://www.uptodate.com/contents/assessment-of-decision-making-capacity-in-adults
Ariella Cohen
M.D. Emergency Medicine
Maimonides Medical Center