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
- 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?
- 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?
- Does the patient appreciate the risks and benefits of the decision and alternatives?
- Does the patient perceive the decision-making to be voluntary or involuntary?
What is the patient's perception of the decision making process?
- 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