conducting-capacity-evaluations

# Conducting Capacity Evaluations

Assesses medical decision-making capacity using the Appelbaum four-abilities framework with structured documentation for clinical, ethical, and legal proceedings.

## Why This Skill Exists

Medical decision-making capacity is the clinical determination of whether a patient can make informed healthcare decisions. It is distinct from legal competency (which is determined by a court). Capacity evaluations are among the most common reasons for psychiatric consultation — approximately 3-25% of hospitalized medical patients lack capacity to consent to treatment. The consequences of getting this wrong are severe: treating a patient without capacity exposes providers to battery claims; respecting the refusal of a patient who lacks capacity may result in preventable death.

The Appelbaum framework (Grisso & Appelbaum, 1998), now universally adopted, defines four functional abilities: understanding, appreciation, reasoning, and expressing a choice. The APA Resource Document on Assessment of Decision-Making Capacity and the MacArthur Competence Assessment Tool for Treatment (MacCAT-T) provide the evidence-based standards. Capacity is decision-specific (a patient may have capacity for one decision but not another), temporally variable (capacity may fluctuate with delirium, medication effects, or time of day), and must be reassessed when clinical circumstances change.

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## Checkpoint A: Pre-Draft Intake (Mandatory)

1. What specific medical decision is at issue? (surgery consent, medication consent, discharge against medical advice, refusal of life-sustaining treatment, enrollment in research, placement in care facility) — default: must be specified
2. Who requested the capacity evaluation? (attending physician, nurse, patient advocate, ethics committee, family) — default: identify requesting party and trigger
3. What is the medical context? (emergent, urgent, elective) — default: assess urgency
4. What is the patient's current mental status? (alert, delirious, sedated, psychotic, cognitively impaired) — default: assess
5. Is there a psychiatric diagnosis or suspected condition affecting capacity? (delirium, dementia, psychosis, severe depression, intellectual disability, intoxication) — default: assess
6. Has the patient previously executed advance directives or designated a healthcare proxy? — default: review chart
7. Are there reversible factors that may be affecting capacity? (medication effects, metabolic derangement, pain, sleep deprivation, untreated psychiatric illness) — default: identify and treat before concluding incapacity
8. What is the risk-benefit profile of the decision? (higher-risk decisions require higher capacity thresholds per sliding-scale model) — default: assess

### Documents to Request

- Medical chart with current diagnosis, treatment plan, and proposed intervention
- Documentation of the decision being presented to the patient (what exactly was explained)
- Nursing notes on patient's behavior and comprehension
- Prior capacity evaluations
- Advance directives, living will, POLST/MOLST, healthcare proxy documentation
- Medication list (identify sedating, anticholinergic, or psychoactive medications)
- Recent laboratory results (metabolic panel, ammonia, drug levels — identify delirium causes)
- Brain imaging if structural pathology is suspected
- Neuropsychological testing results if available
- Ethics committee consultations if applicable

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## Step 1: Preliminary Assessment and Reversible Factor Identification

Before conducting a formal capacity evaluation, determine whether reversible factors are affecting the patient's ability to make decisions:

**Delirium screen (CAM or 4AT):**
- If delirium is present, treat the underlying cause before concluding on capacity
- Document: "Capacity evaluation deferred pending treatment of [identified cause of delirium]. Will reassess in [timeframe]."
- If the decision is emergent and cannot wait for delirium treatment, document the time-pressure and proceed

**Reversible factors to address before concluding incapacity:**
- Pain management (uncontrolled pain impairs cognitive function)
- Medication effects (reduce or hold sedatives, anticholinergics, opioids if safe)
- Metabolic derangements (correct electrolyte abnormalities, treat infection)
- Sleep deprivation (common in ICU settings)
- Sensory deficits (ensure hearing aids and glasses are in place)
- Communication barriers (provide interpreter if language barrier, use assisted communication devices)
- Time of day (if fluctuating, assess at the patient's best time of day)
- Untreated psychiatric illness (treat depression, psychosis, anxiety that may impair decision-making)

Document all reversible factors identified, interventions attempted, and whether capacity was reassessed after intervention.

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## Step 2: Appelbaum Four-Abilities Assessment

For each ability, document the patient's performance with specific examples from the interview. Use open-ended questions followed by targeted probes.

### Understanding
Can the patient understand the relevant information about the proposed treatment?

**Assessment method:**
- Explain the diagnosis, proposed treatment, alternatives (including no treatment), and risks/benefits of each in language appropriate to the patient's educational and cognitive level
- Ask the patient to repeat back the information in their own words (teach-back method)
- Document: What was explained, how it was explained, and the patient's verbatim response

**Adequate:** Patient can accurately paraphrase the key elements of the proposed treatment, its risks, benefits, and alternatives.
**Inadequate:** Patient cannot retain or reproduce the information despite repeated explanations, demonstrates fundamental misunderstanding.

### Appreciation
Can the patient appreciate how the information applies to their own situation?

**Assessment method:**
- "Do you believe you have [diagnosis]?"
- "What do you think [proposed treatment] will do for you?"
- "What do you think will happen if you don't have the treatment?"
- Assess for pathological distortions: denial of illness driven by psychosis or severe depression, delusional beliefs about treatment, irrational optimism or nihilism

**Adequate:** Patient acknowledges (at least to some degree) the illness and its potential consequences, and can apply the treatment information to their own situation.
**Inadequate:** Patient denies having the diagnosed condition due to psychotic denial or severe cognitive impairment, or believes treatment will have magical/delusional effects unrelated to medical reality.

### Reasoning
Can the patient engage in a rational process of manipulating the information to arrive at a decision?

**Assessment method:**
- "How did you decide to accept/refuse the treatment?"
- "What factors are you considering?"
- "Can you compare the option of having the treatment versus not having it?"
- "What makes one option better than the other for you?"
- Assess for consequential reasoning, comparative reasoning, and the ability to weigh risks against benefits

**Adequate:** Patient can describe a logical process for reaching their decision, weigh pros and cons, and consider consequences — even if the decision is one the treatment team disagrees with.
**Inadequate:** Patient cannot engage in any comparative reasoning, cites only irrelevant factors, or shows thought process grossly distorted by psychosis, mania, or cognitive impairment.

### Expressing a Choice
Can the patient clearly communicate a consistent decision?

**Assessment method:**
- "Have you decided whether to proceed with the treatment?"
- "What is your decision?"
- Assess for consistency: Does the patient give the same answer when asked at different times?

**Adequate:** Patient can clearly state a choice that remains relatively consistent over time.
**Inadequate:** Patient is mute, severely ambivalent to the point of paralysis, or gives contradictory answers within minutes without new information.

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## Step 3: MacCAT-T Administration (When Structured Tool is Required)

The MacArthur Competence Assessment Tool for Treatment (MacCAT-T) is a semi-structured interview that operationalizes the Appelbaum framework:

- **Understanding subscale:** 0-6 points (patient's paraphrasing of disorder, treatment, and risks/benefits)
- **Appreciation subscale:** 0-4 points (acknowledgment of condition and potential treatment benefit)
- **Reasoning subscale:** 0-8 points (consequential thinking, comparative thinking, generating consequences, logical consistency)
- **Expressing a choice:** 0-2 points (ability to clearly state a treatment preference)

Note: There is no single cutoff score for incapacity — the MacCAT-T provides a profile of abilities that must be interpreted in clinical context. Lower scores indicate greater impairment but must be integrated with the clinical picture, the severity of the proposed intervention, and the risk-benefit balance.

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## Step 4: Capacity Determination and Documentation

**The sliding-scale model (Drane, 1985):**
- Low-risk decisions with clear benefit (e.g., antibiotics for pneumonia): Low threshold — even minimal understanding and assent may suffice
- Moderate-risk decisions with uncertain benefit: Moderate threshold — reasonable understanding and engagement with the reasoning process
- High-risk decisions with marginal benefit (e.g., refusing life-saving surgery): High threshold — must demonstrate clear understanding, appreciation, and rational reasoning

**Document the clinical opinion:**
1. Specific decision at issue
2. Clinical context (medical condition, urgency, proposed intervention)
3. Psychiatric diagnosis or condition relevant to capacity (if any)
4. Findings for each of the four abilities (with specific examples from the interview)
5. Reversible factors assessed and addressed
6. Sliding-scale consideration (risk level of the decision)
7. Conclusion: "In my clinical opinion, the patient [has/lacks] capacity to make this specific medical decision at this time because [clinical reasoning]."
8. Recommendations (if incapacitated: identify surrogate decision-maker, recommend ethics consultation if contested, reassess when reversible factors are treated)

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## Step 5: Post-Determination Actions

**If patient HAS capacity:**
- Respect the patient's decision, even if it is medically inadvisable
- Document the informed refusal including that capacity was assessed and confirmed
- Ensure the patient understands they can change their mind
- For AMA discharges: document capacity, risks explained, follow-up plan offered

**If patient LACKS capacity:**
- Identify the appropriate surrogate decision-maker (healthcare proxy > spouse > adult child > parent > next of kin, per state hierarchy)
- The surrogate should use substituted judgment (what the patient would want) rather than best interest (what is medically optimal) when the patient's wishes are known
- If advance directive exists, honor it per state law
- If surrogate and treatment team disagree, or if no surrogate is available and the decision is not emergent, refer to ethics committee
- For emergent, life-saving treatment with no surrogate available, treat under implied consent/emergency exception and document the basis
- Reassess capacity when clinical status changes (delirium clears, medication adjusted, psychiatric treatment initiated)

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## Checkpoint B: Post-Draft Alignment (Mandatory)

1. Is the specific decision at issue clearly stated (not a generic "capacity evaluation")?
2. Are all four Appelbaum abilities assessed with specific clinical examples?
3. Were reversible factors identified, addressed, and documented before concluding incapacity?
4. Does the clinical opinion include the reasoning linking findings to the conclusion?
5. Are post-determination actions documented (surrogate identification, ethics referral, reassessment plan)?

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## Quality Audit

- [ ] Specific medical decision identified and documented
- [ ] Requesting party and trigger for consultation documented
- [ ] Delirium screen completed (CAM or 4AT)
- [ ] Reversible factors assessed and addressed before concluding incapacity
- [ ] Understanding assessed with teach-back method and verbatim patient response
- [ ] Appreciation assessed with specific questions about illness acknowledgment
- [ ] Reasoning assessed with comparative and consequential reasoning probes
- [ ] Expressing a choice assessed with consistency check
- [ ] Psychiatric diagnosis or condition affecting capacity identified
- [ ] Sliding-scale consideration documented (decision risk level)
- [ ] Clinical opinion clearly stated with supporting reasoning
- [ ] Surrogate decision-maker identified (if incapacitated)
- [ ] Advance directives reviewed and documented
- [ ] Reassessment plan documented (if incapacity may be reversible)
- [ ] Ethics consultation recommended if contested or complex

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## Guidelines

1. Capacity is decision-specific — never document "patient lacks capacity" globally. A patient may lack capacity to refuse cardiac surgery but retain capacity to choose their meal preferences.
2. A patient's decision to refuse treatment does not equal incapacity — disagreement with medical recommendation is not, by itself, evidence of impaired capacity. The evaluation assesses the process, not the outcome, of decision-making.
3. Always assess and address reversible factors before concluding incapacity — declaring a delirious patient incapacitated without treating the delirium is premature and may deprive the patient of the opportunity to participate in their care.
4. Document the capacity assessment in the medical record even when the patient is found to have capacity — this protects both the patient and the treatment team.
5. Capacity evaluation is a clinical determination, not a legal one — if legal competency determination is needed (guardianship, conservatorship), a court proceeding is required.
6. The sliding-scale model should guide the threshold for capacity — higher-risk, lower-benefit decisions require higher capacity than lower-risk, higher-benefit decisions.
7. Re-evaluate capacity when clinical circumstances change — new information, change in medical status, treatment of reversible factors, or passage of time may alter capacity.