Patient capacity
Patient capacity
Establishing patient decision-making capacity is a cornerstone of the informed consent process and the overall preoperative evaluation. Obtaining an adequate history and providing postoperative instructions is not possible without a patient’s ability to accurately understand and make medical decisions on their own behalf. For the vast majority of patients, this is not a problem, but for a few patients, the ability to understand is a significant and delicate issue. Culturally, a stigma is often associated with mental incompetence, and questioning an elderly patient’s abilities can interfere with rapport, potentially making them angry or defensive. Furthermore, those with functional impairments may hide their diminished capacity well. It is important to understand that competence is a legal term, which is commonly confused with capacity —a physician assessment. For informed consent, a patient must be capable of understanding the procedure and relevant information, making a rational choice, and understanding any potential complications or consequences. A patient’s family can provide significant insight into capacity and/or competency status. Oftentimes, the family may be quick to provide information that the patient requires a co-signer or legal guardian present for paperwork, which makes the process straightforward. The dynamics between the patient and their family may also hint at capacity; repeating instructions in different wording, family leading the conversation, and visible frustration may be cues that suggest the need for a more thorough mental status examination. If unaccompanied, the physician should pay close attention to the patient’s general hygiene, coordination, and speech patterns. If ever in question, simple questions like “where do you live?” or “how did you get here?” are innocuous queries that evaluate mental status without prompting any perceived stigmatization.
During the initial evaluation, it is important for all members of the team to quickly asses the patient’s overall state of mind. Are they anxious? Confident? Overly worried about cosmetic appearance? With this information, the best support can be offered by the team. Indeed, adequate psychological support cannot be overemphasized for a smooth and successful outcome.
Of course, minors cannot provide true consent for any procedure, though their assent is important. Some patients under 18 may look older than they are (and vice versa), so it is important when operating on young adults to check their date of birth. Be sure any child’s parent or legal guardian gives the consent. This can generally be performed with a phone consent as long as it is witnessed by having a staff member join on the phone to verify the consent.