People with severe and persisting mental illness, such as schizophrenia, bipolar disorder and major depression form one of the most vulnerable groups in society. A comprehensive evaluation of capacity is of utmost importance to help achieve a balance between the right to self-autonomy on one hand and beneficence, on the other. However, this type of assessment is only conducted once the person’s condition has stabilised and in the context of a specific trigger or need. When an individual is acutely unwell (e.g., with an acute psychotic episode or severe mood disturbance) the treating psychiatrist may address any consent to treatment-related issues under the applicable State mental health legislation.
Typical referral scenarios
Anne is a 60-year-old woman with chronic schizophrenia characterised by ongoing psychosis and negative symptoms. She has lived independently for most of her life, but over the past year her ability to care for herself has deteriorated despite stability of her underlying psychiatric condition. She has refused support services and was referred for assessment of her ability to make decisions relating to services and accommodation.
Brian is a 40-year-old man with chronic schizophrenia who has lived with his mother all his life and under her direction was able to assist with household chores and paying bills. Brian’s mother died last year and he has been living on his own in the inherited family home. He was recently admitted to hospital with acute psychosis after non-compliance with medication, bills left unpaid and his home found in a state of squalor. Once stabilised, Brian was referred for assessment of his capacity to manage his affairs and make decisions regarding services and accommodation.
Cathy is a 50-year-old woman with bipolar disorder and Cluster B personality traits. Her mental state is reasonably stable, but there have been concerns about her cognitive function in the past. She has recently been diagnosed with a medical condition and was referred for assessment of her capacity to consent to dialysis.
Practice and ethical considerations
Capacity is decision-specific and time-specific. For example, even though Brian (above) might lack the capacity to manage his financial affairs, he may still retain the capacity to make service and accommodation-related decisions. Individuals such as Cathy may experience fluctuations in their mental state, so it is important to conduct the capacity assessment as close as possible to when the decision needs to be made and be mindful that capacity may be regained. The clinician should remain cognisant that in law, all adults are presumed to have capacity, unless otherwise demonstrated.
The individual should be asked about the current situation, using open-ended questions wherever possible as ‘yes’ or ‘no’ responses cannot sufficiently demonstrate an adequate understanding of the issues. Individuals should be given the opportunity to show their understanding of the facts, the main options available and the implications (advantages/disadvantages) of those options. They should be able to arrive at a decision and communicate this in a consistent manner. Importantly, it is the decision-making process that is evaluated rather than the decision itself; individuals are entitled to make decisions that others might not agree with. If the individual is not aware of the relevant facts, options or implications, these should be explained, following which the decision-making process should be re-evaluated.
For support and accommodation-related issues, the assessment should look for evidence of objective functional decline (e.g., lack of food, poor hygiene). If this is apparent, is the individual at risk of harm? Has the least restrictive option been implemented? What is the level of insight into these issues? For matters relating to the management of financial affairs, does the individual have experience managing his or her affairs in the past? Is there risk that funds might be dissipated or lost? Is there an understanding of when to seek professional advice and a willingness to do so?
Gathering information from other sources is a key factor in the evaluation of capacity. In the hospital setting, this can be gained through discussion with members of the treating team. With the individual’s consent, interview with family members or friends may also prove informative.
Considerations for test selection and interpretation
Tests are administered to evaluate performance across the various domains of cognitive function. The specifics vary from case to case, however, in this population, it is important to include measures of attention, memory and executive function.
The results of cognitive testing may inform the impressions gained on clinical interview, but poor performance on testing does not equate to a lack of capacity. In some cases, the test results may serve to identify areas of strength and weakness, which can then be used to support the patient in the decision-making process. For example, Brian might struggle to absorb, understand or remember overly complex information, but when the reasons for engaging support services are explained to him in a straightforward and succinct manner this may facilitate his ability to make decisions for himself.