Article Figures & Data
Figures
Figure 1. Capacity in a patient who has decisional capacity but is at foreseeable risk of losing decisional and functional capacity. A patient with a known diagnosis that is associated with fluctuating capacity because of treatment nonadherence can alternate between periods of capacity and incapacity over time (solid line). At the time of a capacity evaluation (dashed line), a patient may be capacitated. Whether a patient has a period of brief stability, its duration, and the acuity of decline in capacity (dotted line) will vary based on the nature of the patient’s condition and the effect of nonadherence, either partial or full.
Tables
- Table 1
Example Conditions in Which Capacity Can Fluctuate Because of Treatment Nonadherence
Condition Treatment Being Declined At-Risk Mental State Conditions Leading to Delirium-Spectrum States Hypertensive urgency or emergency Antihypertensive, typically parenteral Hypertensive encephalopathy with or without posterior reversible encephalopathy syndrome Severe infection, especially sepsis Antibiotics, typically parenteral Septic encephalopathy Acute or decompensated kidney failure Renal replacement therapy Uremic encephalopathy Acute or decompensated liver failure Lactulose, rifaximin, et al. Hepatic encephalopathy Brain metastases Corticosteroids Increased intracranial pressure presenting with delirium, seizures, or brain herniation Severe chronic obstructive pulmonary disease Home oxygen Hypoxic encephalopathy Insulin-dependent diabetes (“brittle diabetes”) Insulin, dietary discretion Diabetic ketoacidosis or hyperosmolar hyperglycemic syndrome, either presenting with seizures or delirium Congestive heart failure Diuretics, fluid discretion Delirium because of several different electrolyte disturbances Active substance use disorder A range of potential offerings (e.g., rehabilitation) Intoxication or withdrawal, either of which could present with delirium Primary Psychiatric Conditions Schizophrenia with thought disorganization Antipsychotic medications Thought disorganization Psychiatric disorder presenting with catatonia Lorazepam Catatonia - Table 2
Applying the Traditional Skills of Decisional Capacity to a Patient Who Is at Foreseeable Risk of Losing Decisional and Functional Capacity
Skills of Capacity Applying to a Patient at Foreseeable Risk of Losing Decisional and Functional Capacity Foreseeability Risk Acuity Nature of Incapacity Decisional Relevance Communicate a consistent choice Communicate a consistent choice Communicate a consistent choice Communicate a consistent choice Communicate a consistent choice Understand the risks and benefits of an intervention Understand the predicted high degree of likelihood (foreseeability) of the future incapacity Understand that the acuity of risk could be imminent, precluding in-the-moment attempts to seek care or assistance of others Understand the consequences of such a mental state, which could include death or irreversible injury Understand that alternative decisions could mitigate, if not eliminate, this risk Appreciate the situation (insight) Appreciate future likelihood (or past history) of decisional and functional incapacity because of the clinical condition in question Appreciate that incapacity could occur suddenly, within minutes to hours, and very likely without warning Appreciate that the anticipated state of incapacity would entail lack of awareness of the risk or inability to care for or protect self (appreciation should entail meaningful problem solving and attempts on the part of the patient to mitigate risk) Appreciate that the decision in question directly creates risk Deliberate rationally Demonstrate rational prediction (including realistic, evidence-based appraisal based on any available evidence, such as evidence of prior such incapacity) regarding potential for future incapacity Demonstrate rational problem solving based on potential acuity of risk Demonstrate rational planning in response to anticipated incapacity Demonstrate metacognition (including entertaining hypothetical scenarios) about future self
