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Capacity assessment: A fundamental skill

A patient’s ability to understand, retain, and use information and communicate decisions are factors in establishing capacity

Vol. 10, No. 09 / September 2011

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Because psychiatrists may be asked to determine if a hospitalized patient has the capacity to consent to or refuse treatment, capacity assessment is a fundamental skill. Every patient has a right to refuse or accept treatment and a psychiatric diagnosis by itself doesn’t make a person incapacitated. Each patient is assumed to have capacity until proven otherwise and the burden of proof lies on the physician who performs the assessment.1,2 Consent obtained from an incapacitated patient is invalid and obtaining such consent can lead to legal proceedings.1,2 This article highlights strategies for capacity assessment for psychiatrists.

A patient may need a capacity assessment if he or she refuses a procedure, treatment, placement, or food; wants to leave against medical advice; or is a candidate for organ transplantation.3 Physicians might consult psychiatry for a capacity assessment because they fear medico-legal consequences, do not understand patients’ right to refuse treatment, lack the skills necessary to perform a capacity assessment, have a poor relationship with a patient, or are not comfortable performing such assessments on a patient with a psychiatric diagnosis.3

Physicians should advocate for patients and take measures to protect them from harm while respecting their autonomy. This can be challenging if there are doubts about the patient’s cognitive abilities. Collateral information from family and other allied health care professionals can help in distinguishing what patients say from the facts.

Assessing capacity: Key questions

Various instruments are available for capacity assessment, including the MacArthur Competence Assessment Tool for Treatment, a structured interview that takes approximately 20 minutes to administer and score. A Mini-Mental State Examination (MMSE) can be a starting point for evaluating capacity, especially in geriatric patients.1,2 An MMSE score <19 is likely to be associated with a lack of capacity.1 However, there is no substitute for clinical judgment.

Asking a few key questions can help determine if a patient meets 4 criteria in relation to a specific treatment decision:1

Ability to understand relevant information. Ask patients to explain to you what’s wrong with their health, what’s being done, and the recommended treatment plan.

Ability to retain information. Question patients to see if they can recall details of previous discussions.

Ability to use or weigh information. Ask patients if they understand the risks and benefits of treatment options, including the recommended plan and alternatives. Also ask about the consequences of not getting treatment.

Ability to communicate a decision. Ask patients to indicate whether they agree or disagree with the physician’s recommendation.

A patient can be considered competent to make a treatment decision if he or she can understand and retain information about his or her condition, appreciate the consequences of his or her choices, and weigh the relative risks and benefits of the options.1


The authors have no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.


1. Applebaum PS. Clinical practice. Assessment of patients’ competence to consent to treatment. N Engl J Med. 2007;357(18):1834-1840

2. Church M, Watts S. Assessment of mental capacity: a flow chart guide. The Psychiatrist. 2007;31:304-307

3. Jourdan JB, Glickman L. Reasons for requests for evaluation of competency in a municipal general hospital. Psychosomatics. 1991;32(4):413-416

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