Respecting Patient Rights

Basic Bioethics For Residents, CCF Residency Programs, November 28, 2000

I. Communicating with Patients and Families
II. Informed Consent: Empowering Patient Participation in Decision Making
III. Assessing Patients' Decisional Capacity
IV. Maintaining Patient Confidentiality
V. Honoring Patients' Advance Directives

III. Assessing Patients' Decisional Capacity

The President's Commission for the study of ethical problems in medicine and biomedical and behavioral research (1982) identified essential elements that patients should demonstrate if they are to be judged capable of making their own health care decisions (i.e, that they have "decisional capacity"):

  • Possession of set of values and goals
  • Ability to communicate and understand information
  • Ability to reason and to deliberate about choices

The following staged questions are useful when a physician must assess a patient's decisional capacity.

  1. What is the question to be decided: what decision needs to be made? Is the diagnosis certain? Is there consensus about diagnostic or treatment alternatives? What is clinically at stake in the decision?
  2. Has the patient been adequately informed about the medical condition and treatment alternatives? The physician should determine this independent of the assessment of the patient's decisional capacity. Repeat assessment after informational deficiencies have been corrected. Does the patient understand the medical condition and how it relates to the decision?
  3. Does the patient appreciate the risks and benefits of the decision and alternatives?
  4. Does the patient perceive the decision-making to be voluntary or involuntary? What is the patient's perception of the decision making process?
  5. Can the patient reason consistently about the medical condition, the decision, and their stated beliefs and values?

As part of the assessment, the physician should corroborate patient values and beliefs by speaking with the patient's,

  • Family and friends
  • Advance Directives
  • Existing medical records
  • Other health care professionals.
  • Information from adjunctive sources (e.g., family, neighbors, agencies, prior medical record)

Other factors exist that can influence or complicate assessment of decisional capacity, but that do not in themselves invalidate a patient's decision making abilities. Physicians should be attentive to the following factors that can adversely or positively influence a patient's decisional ability:

  • The patient's mental status
  • Support mechanisms or systems available to the patient
  • Psycho-dynamics and interpersonal situation
  • Pharmacological background
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