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
Skills of 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