It’s a spiral staircase, not just two steps: An iterative approach to assessing patient capacity for medical decision-making

• Published in: Patient education and counseling 2024-10, Vol.127, p.108362, Article 108362
• Main Authors: Tunzi, Marc, Day, Philip G., Satin, David J.
• Format: Article
• Language: English
• Subjects: Clinical Decision-Making; Clinician-patient communication; Decision Making; Humans; Informed Consent; Medical decision-making capacity; Mental Competency; Patient Participation; Physician-Patient Relations
• ISSN: 0738-3991; 1873-5134; 1873-5134
• DOI: 10.1016/j.pec.2024.108362

The assessment of medical decision-making capacity as part of the process of clinical informed consent has been considered a bioethical housekeeping matter for decades. Yet in practice, the reality bears little resemblance to what is described in the medical literature and professed in medical education. Most literature on informed consent refers to medical decision-making capacity as a precondition to the consent process. That is, a clinician must first determine if a patient has capacity, and only then may the clinician engage with the patient for the rest of informed consent. The problem with this two-step approach is that it makes no sense in actual practice. We see the assessment of medical decision-making capacity within the process of informed consent as a spiral staircase, not just two steps, requiring clinicians to keep circling up and around, making progress, until they get to where they need to be: 1. Clinicians start with a general presumption of capacity for most adults, sometimes having a provisional appraisal of capacity based on prior patient contact. 2. Then, they begin performing informed consent for the current situation and intervention options. 3. Next, they must reassess capacity during this process. 4. After that, they continue with informed consent. 5. If capacity is not yet clear, they repeat 1–4. •Patient capacity for medical decision-making is the most challenging element of informed consent both in theory and in practice.•The literature typically describes medical decision-making capacity as a theoretical precondition to informed consent.•In practice, assessing medical decision-making capacity is an iterative activity within the process of informed consent.