special subjects
Capacity (Competence) and Incapacity
Clinical capacity
Clinical capacity to make health care decisions is the ability to understand the potential benefits and harms of the proposed health care, to understand possible alternatives, and to make and communicate a health care decision. Assessment of this capacity requires evaluation of the following: Medical factors (eg, the patient's medical condition, sensory deficits, drug adverse effects, emotional and psychiatric issues) Functional abilities (physical, cognitive, and psychologic) Environmental factors (eg, stressful living conditions, availability of helpers, isolation, time of day variations cased by medication schedules or fatigue) Appropriate health care professionals determine this type of capacity when needed and document the determination process. Qualified health care professionals, as defined by state laws, are legally empowered to make these determinations in almost every state under state advance directive laws. The courts become involved only when the determination itself or another aspect of the process is challenged by the patient or someone else. Clinical capacity is specific to a particular health care decision and thus is limited to that decision. The level of clinical capacity needed to make a health care decision depends on the complexity of that decision. A patient with some decrease in capacity, even one with fairly severe cognitive deficits, may still have enough capacity to make simple health care decisions, such as whether to allow a rectal examination or placement of an IV. Importantly, a patient with some decrease in capacity may still have enough capacity to designate a Consent and Surrogate Decision Making ( Clinical capacity is specific to a particular health care decision and thus is limited to that decision. All feasible attempts should be made to involve the patient in decision making. Ignoring the decision of patients with capacity or accepting the decision of patients without capacity is unethical and risks civil liability. A patient's ability to carry out a decision is also important for physicians to assess. For example, a patient with a broken leg may be able to make the decision to return home but be incapable of self-care during convalescence. Providing the necessary support to carry out a decision becomes an important goal of care. Capacity may be intermittent, variable, and affected by the environment. Patients who lack capacity due to intoxication, Delirium , 