Judging capacity is not the same as judging competency. Consultations from other services may (e.g., can a patient refuse to get some operation?) may sometimes be called 'competency' but such decisions are actually ones of capacity. ★The key is that competency results from a judicial decision and capacity from a psychiatric one.
Capacity
Simply put, capacity is the ability to understand and participate in medical treatment. On a psychiatric unit, capacity has a more limited meaning, which is discussed first.
Capacity to take psychiatric medications is defined under LPS law in California and is colloquially referred to a Riese petition. This stems from a court case known as Riese vs. St. Mary's Hospital regarding the decision that a patient does not have capacity to refuse psychiatric medications. A capacity petition is filed and an in-unit hear is held.
On the consultation service, psychiatrists are asked to assess patient's capacity to participate in a medical decision. This usually relates to refusing a necessary treatment or agreeing to one that is higher risk. ★If a patient is refusing treatment and a psychiatrist finds the patient to lack capacity, this does not mean the treatment can be administered. It means there must be substitute consent.
To have capacity, a person must:
A core script involved in a capacity interview is provided here.
Some researchers have suggested that competency could be balanced between two variables: the risk-benefit ratio and the patient's decision. This is illustrated in the table below.
| Treatment risk-benefit ratio | ||
| Patient's decision | Favorable outcome likely | Unfavorable or questionable outcome possible |
| Consent | Low threshold for capacity | High threshold for capacity |
| Refuse | High threshold for capacity | Low threshold for capacity |
Capacity is fluid, so some patients may require repeat assessments because of their changing condition.
When assessing capacity, if a patient is refusing a potentially life-saving intervention, it is best to document with specific quotes and, depending on the case, have another person present to document the interview. Note that although a score on the Mini-Mental State Exam may often be correlated with capacity, it is not itself a measure of capacity. ★One should remember to ask open-ended questions when evaluating capacity.
If a patient is found to lack capacity, then the family and/or treatment team should pursue a court-appointed surrogate. Note that if the procedure is eminently life-threatening, it can be declared emergent and then carried out
Leaving AMA
Psychiatry consultations are often called if a patient wishes to leave the hospital against medical advice. Any patient who has capacity can leave against medical advice. The patient must understand the risks involved in not following medical advice as well as the possible consequences.As in most instances, documentation is vital. However, even if the patient lacks capacity, unless he or she meets criteria for an LPS hold, there is not much a psychiatrist can do except try to work with the patient and family. ★Put more or hen he directly, if a patient is not LPS-holdable, then there is nothing a psychiatrist can do to detain the patient.