Required elements of decisional capacity and competence
| Decisional element . | Definition . | Case example . |
|---|---|---|
| Understanding | The patient’s ability to grasp the meaning of information communicated by the physician and other caregivers. | Ms. Haverford has just been diagnosed with an advanced hematologic malignancy, but she has been completely silent while her physician explains her the diagnosis and recommended treatment. Further inquiry is necessary to ensure that she understands the information that has been communicated to her. |
| Appreciation | The patient’s ability to appreciate the consequences of their situation (medical condition, need for treatment [when applicable], and likely benefits and harms of each possible treatment). | Ms. Haverford is a highly educated patient who has clearly understood the information conveyed, but she seems to question how certain it is that she really has cancer and thus whether any treatment is actually needed. Exploration of her appreciation of his condition is clearly needed. |
| Reasoning | Patient can weigh risks and benefits within/across treatment options and arrive at a decision that is consistent with their starting premise(s). | Ms. Haverford has been clear that she places great value on comfort but elects a treatment approach that is likely to cause substantial distress. This discordance deserves a careful inquiry into the reasoning underlying that decision. |
| Communicating a choice | Patient can clearly indicate the preferred treatment option and maintain that choice for a sufficient period of time for it to be implemented. | Ms. Haverford demonstrates great ambivalence about a treatment choice, not clearly embracing any option but shifting among them. The basis for that ambivalence should be explored and, if possible, resolved. |
| Decisional element . | Definition . | Case example . |
|---|---|---|
| Understanding | The patient’s ability to grasp the meaning of information communicated by the physician and other caregivers. | Ms. Haverford has just been diagnosed with an advanced hematologic malignancy, but she has been completely silent while her physician explains her the diagnosis and recommended treatment. Further inquiry is necessary to ensure that she understands the information that has been communicated to her. |
| Appreciation | The patient’s ability to appreciate the consequences of their situation (medical condition, need for treatment [when applicable], and likely benefits and harms of each possible treatment). | Ms. Haverford is a highly educated patient who has clearly understood the information conveyed, but she seems to question how certain it is that she really has cancer and thus whether any treatment is actually needed. Exploration of her appreciation of his condition is clearly needed. |
| Reasoning | Patient can weigh risks and benefits within/across treatment options and arrive at a decision that is consistent with their starting premise(s). | Ms. Haverford has been clear that she places great value on comfort but elects a treatment approach that is likely to cause substantial distress. This discordance deserves a careful inquiry into the reasoning underlying that decision. |
| Communicating a choice | Patient can clearly indicate the preferred treatment option and maintain that choice for a sufficient period of time for it to be implemented. | Ms. Haverford demonstrates great ambivalence about a treatment choice, not clearly embracing any option but shifting among them. The basis for that ambivalence should be explored and, if possible, resolved. |
The table describes the fictional case of Ms. Haverford, who was recently diagnosed with an advanced hematologic malignancy. Whereas Mr. Smith’s team appeared to have no concerns about his capacity and competence, this table describes the fundamental elements of decisional capacity and competence, and how these might apply in a case such as that of Ms. Haverford.
Table adapted with permission. Copyright 2020 American Society of Clinical Oncology. All rights reserved. Adapted from Marron et al, 2020.9