Changes in decision making capacity during illness: a review and case report with implications
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Arch Psych Psych 2008;10(4):47–55
Mental health professionals in general hospital settings are frequently asked to provide consultative opinions about patients' capacity for medical decisions and self-care. Adult patients are assumed to be autonomous decision makers unless they have been determined to be incompetent through a judicial proceeding. In reality, however, clinical judgements of incapacity are often accorded the status of law. Treatment, when seen as in the patient's best interest, may proceed against the patient's explicit wishes. In addition, capacity decisions are often viewed as fixed, enduing states even though many medical conditions adversely affecting decisional skills are reversible. Ms. Thornton, a 37-year-old woman, admitted for a ruptured cerebral aneurysm, underwent three capacity evaluations during her six week hospitalization. At the first two assessments separated by about two weeks, she demonstrated little understanding of her condition, treatment options, and likely outcomes with and without intervention. At the third assessment, six weeks after admission, Ms. Thornton had regained adequate decisional capacity and was subsequently discharged. Clinicians conducting capacity evaluations in an era of brief hospitalization, with accompanying pressures to rapidly discharge patients, should include attention to both medical and psychiatric conditions, which when treated, lead to regained capacity.