For Residents

Assessing decision-making capacity

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Medical and surgical inpatient teams often consult psychiatrists to help assess a patient’s decision-making capacity (DMC). Completing a DMC assessment can be a source of stress and frustration for psychiatry residents; however, the process can be significantly improved by following a consistent and focused psychiatric interview. In our institution, the most frequently used tool for assessing DMC is the Aid to Capacity Evaluation (ACE).1 The American Academy of Family Physicians offers a printer-friendly adaptation2 of the ACE assessment.

Reasons for a DMC consultation

When accepting a DMC consultation, make sure to specify for which medical decision the primary team would like the patient to be evaluated so that the consultation can be most helpful and specific to primary team’s concerns.3 The 4 most common reasons for a DMC consultation are:

Acute changes in mental status. These changes may be due to hypoxia, infection, medication, metabolic disturbances, or other medical conditions. Often, the diagnosis is delirium due to a medical condition, and assessing for DMC is deferred until the delirium resolves.

Refusal of a recommended treatment. One of the most frequent reasons for a DMC consultation is when a patient declines the primary team’s treatment recommendations. These recommendations may include medications, interventions (procedural or surgical), or discharge planning (such as transfer to a rehabilitation facility or skilled nursing care facility).

Consenting to a risky or invasive treatment too hastily. This occurs less often than the other 3 scenarios, most likely because capacity is rarely questioned when a patient’s decision aligns with the physicians’ recommendations.

Having risk factors for impaired decision-making. One of the most common reasons for involving psychiatry in a DMC consultation is when the patient has a risk factor that may impair his/her decision-making.

These risk factors include:

  • a chronic psychiatric or neurologic condition
  • a significant cultural or language barrier
  • a low or unknown education level
  • anxiety or discomfort with institutional health care settings
  • age <18 or >85.

Continue to: When should you put off a DMC consultation?


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