Criteria to evaluate decision-making capacity for consent

Dr KK Aggarwal

Consent taking is an integral part of clinical practice. Doctors are required to obtain informed consent from their patients before initiating treatment or carrying out any procedure, therapeutic or diagnostic.

The concept of consent is derived from the ethical principle of patient autonomy. Consent is therefore an ethical obligation and legal requirement. 

There are three components of a valid consent:

·         The patient gives it voluntarily without any coercion

·         The patient has the minimum of adequate level of information about the nature of the procedure to which he is consenting to.

·         The patient has the capacity and competence to give consent

Criteria that have been deemed to be necessary to reach to a decision by the patient regarding his/her treatment have been defined: Understanding, expressing a choice, appreciation and reasoning. Assessment of these criteria for decision making capacity is an essential part of the process of informed consent.

Understanding: Is the patient able to grasp or comprehend the meaning of the information provided to him/her by the doctor and retain that knowledge?  This includes information about the disease condition, the proposed treatment or alternative treatments, the associated benefits and risk of proposed treatments, alternative treatments as well as no treatment. The ability to understand the relevant facts has a great role in the decision making ability of the patient. Because if the patient does not understand the information given, he/she cannot pick information that is relevant to their situation. The information must be simple and clear and imparted in language, which the patient can understand, avoiding too many medical terms. Memory problems, intelligence can affect understanding of the information.

Expressing a choice: Is the patient able to clearly communicate to the doctor his/her choice of preferred treatment option from the multiple proposed treatment options and is the patient able to maintain a relatively stable decision regarding treatment choice for it to be implemented? Patients may often change their mind about their treatment choice and withdraw consent at any time. This does not mean that the patient lacks the capacity to make a decision if the patient is able to give a justifiable rationale for the change in decision. However, frequent changes in decision making may put a question mark on the capacity of the patient to come to a decision.

Appreciation: This component goes beyond the mere understanding of the facts given to a patient. Is the patient able to relate the information about the proposed diagnostic and treatment intervention and the likely consequences to himself/herself directly? Whether the patient understands the consequence of refusal of treatment?

Reasoning:  Is the patient able to rationally use the relevant information and give reasons for selecting a particular treatment option keeping his best interests in mind? This component deals with the process by which the patient arrives at a decision and not the final decision as chosen by the patient. If a patient lacks reasoning, he/she will not be able to compare the benefits and risk of various treatment options in a rational or logical manner. Reasoning is affected in conditions like psychosis, depression, any phobia, dementia.