Decision-Making Capacity of Psychiatric Patients Is Ethically Complex
March 1, 2025
By Stacey Kusterbeck
Clinicians often have difficulty assessing decision-making capacity in psychiatric patients. One reason is that capacity can fluctuate based on the patient’s condition or treatment. “As ethicists, our role is not to determine whether a patient has decision-making capacity, as this is a clinical assessment conducted by a physician. However, ethicists can play a crucial role in ensuring that patient autonomy is respected to the greatest extent possible,” says Lianne Glaus Vighetti, DHCE, HEC-C, LCSW, a medical ethicist at UPMC Presbyterian/Shadyside.
When patients lack decision-making capacity related to a specific medical concern, some still can express preferences. Patients can identify somebody they trust to make decisions, for example. “We can then work in a collaborative decision-making process. The team, the patient, and the surrogate are all working together, doing what we can to honor the patient’s preferences,” says Vighetti.
Patients’ decision-making capacity can fluctuate for a variety of reasons and can have both reversable and irreversible causes. For example, a patient experiencing active psychosis may lack decision-making capacity, but this could improve with treatment (such as medication). “When providers receive education on decision-making capacity, it is crucial to emphasize that decision-making capacity can fluctuate. It’s not an all-or-nothing phenomenon. There can be many factors that can cause capacity to wax and wane,” explains Vighetti. For instance, the decision-making capacity of patients with dementia can vary based on the time of day.
Clinicians often use the terms “capacity” and “competency” interchangeably. “However, they are not the same thing,” says Vighetti. Capacity is a clinical determination that relates to a specific decision that needs to be made: Does the person have the capacity to refuse to go to a skilled nursing home? “Competency is a global determination that can only be made by a judge,” says Vighetti. Ethicists can help in these ways, offers Vighetti:
- Ethicists can document in the medical record that there is a need to reassess capacity as the patient’s clinical situation changes. For instance, ethicists can put a note in the chart such as, “Now that the patient is extubated, I recommend that the clinical team engages in daily capacity assessments to see if the patient is able to make an informed decision about the medical question at hand.” “First-person consent is always preferred,” emphasizes Vighetti.
- During consults, ethicists can encourage the team to conduct ongoing capacity assessments if it is clinically appropriate to do so.
- Ethicists can help clinicians to understand the ethical justification behind decisions to treat over a psychiatric patient’s objections.
- Ethicists can remind clinicians of the need to respect the autonomy of psychiatric patients. Sometimes, the psychiatric patient has capacity and makes a decision that clinicians do not think is in the patient’s best interest. “It is an uncomfortable feeling when, as providers, we suggest something that we believe is beneficent and will help a patient to avoid harm, and the patient refuses. That is a struggle for all of us,” says Vighetti.
Capacity assessment of psychiatric patients can be among the most difficult ethical challenges that clinicians face in the hospital setting, according to Jacob M. Appel, MD, JD, MPH, HEC-C, director of ethics education in psychiatry at Icahn School of Medicine at Mount Sinai and an attending physician at Mount Sinai Health System. Appel says physicians must answer these ethical questions: To what degree should psychiatrists defer to a patient’s longstanding beliefs, even if they appear highly irrational? How long does someone have to possess a belief before it becomes longstanding?
Adding to the challenge is that a wide range of factors can impair capacity, including intoxication, delirium, dementia, and psychosis. Other conditions, such as severe depression, can diminish a patient’s capacity. The ethical question is: How diminished must a patient’s capacity be to lose their decision-making power? “This is highly subjective. And the stakes are extremely high, as deciding a patient lacks capacity to make a medical decision overrides one of that individual’s most basic rights,” says Appel.
It is important for clinicians to bear in mind that decision-making capacity is specific to individual decisions. A psychiatric patient may have the capacity to make some medical decisions (especially those with lower stakes) but not others. For instance, a psychiatric patient may understand the risks and benefits of having their vital signs checked or their blood drawn. That same patient may lack capacity to decline an emergency appendectomy.
“Delirious patients may literally have capacity to make a decision at one moment but not [be able to] 10 minutes later. That is why assessment should occur as close to the time of the proposed medical intervention as possible,” says Appel.
Clinicians often have difficulty assessing decision-making capacity in psychiatric patients. One reason is that capacity can fluctuate based on the patient’s condition or treatment.
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