Capacity

A clinical determination of a patient's ability to make decisions about treatment interventions or other health-related matters.

Capacity is determined by the health care practitioner or, ideally, by the health care team with the aid of cognitive testing, discussion over time, and observation. Capacity is related to memory but is not extinguished by memory loss.

Persons are considered to have decisional capacity if they can understand their health condition; can consider the benefits, burdens, and risks of care options; can weigh the consequences of treatment against their preferences and values; can reach a decision that is consistent over time; and can communicate that decision to others.

Elderly patients with decisional capacity have the same rights as other adults to make choices about their care. Because many elderly patients can make some decisions but not others, capacity is considered decision-specific. Thus, a patient may be capable of choosing between relatively benign alternatives that may have few serious consequences but may not be capable of evaluating and choosing alternatives in a life-threatening circumstance.

For the elderly, who are often deprived of the opportunity to make any decision when they are unable to make some, the notion of partial capacity is especially important. Many elderly patients have diminished or fluctuating capacity and can be supported in their exercise of some autonomous decision making. For example, patients who become confused at the end of the day (sundowning) can make health care decisions when they are lucid. These decisions can then be recorded in the patient's medical chart. Patients with short-term memory loss may still be able to judge the appropriateness of a suggested intervention, especially if they have shown a long-standing pattern of stable choices that can be corroborated. If, however, patients must retain current information to choose among treatment options, then short-term memory loss is relevant (eg, if memory is needed for compliance with certain rehabilitation regimens, then it is relevant).

A patient's autonomous right to make health care decisions may be compromised by a physician's finding that the patient lacks capacity. The patient may therefore be at risk of disempowerment, especially in acute care settings. In this setting, the effects of illness, drugs, or postsurgical delirium can exclude patients from discussions about care plans. In addition, hospitalization, which may scare, confuse, or intimidate the patient, can compound common problems of aging (eg, loss of hearing or sight). For the already incapacitated patient, hospitalization may precipitate a crisis for which surrogates must be identified, hastily assembled, informed of choices, and helped to sort through care options preferred by or in the best interest of the patient.

The burden of making decisions for an incapacitated patient falls heavily on both family and care providers. Therefore, whenever possible, health care professionals should discuss treatment options and preferences while the patient still is capable of making and communicating informed choices. These expressed preferences should be recorded in the patient's medical chart and documented in an advance directive.