Competency

• Legal term - ability to understand the nature of an act
• Adults are competent until determined otherwise by a judge
• Fairly persistent label; not cross-sectional

If patient is competent...do they have capacity?

Capacity

• Cross-sectional ability to make informed decisions
• Medical decision-making (e.g. consent; leaving AMA; etc.) = requires patient to be able to do all 4 below
• Appreciate situation/illness (appreciation = understanding + application to their personal situation)
• Appreciate risks, benefits, side-effects, alternatives to proposed intervention
• Rational reasoning in manipulation of the data (not necessarily reasonable reasoning)
• Not influenced by effects of medical illness, e.g. depression/suicidality
• Consistently communicate a choice
• Frequently requires judgement calls...
• If patient lacks capacity
• Find out if patient has health care proxy and/or advance directives
• Health care proxy = designated power of attorney (DPOA) = legal document empowering a designated person to make decisions in the event the patient cannot
• Advance directives = living will = document providing instructions for specific situations should the patient be rendered incapacitated
• If not, follow chain of surrogate decision makers (check state laws)
• Spouse, adult parent, adult child...
• Exceptions to requiring informed consent
• Medical emergency - when delay of treatment poses imminent risk, MD may act in patient's best interest
• Adjudicated incompetent - court-appointed legal guardian must give consent regardless of pt capacity 
• Patient waiver - pt may waive the right to informed consent "Do whatever you think is best"

When to call psych consult for ?capacity

• Psychiatric process impacting decision-making
• Psychosis
• Delirium/dementia
• Depression/mania
• Acute intoxication
• Intellectual disability
• High risk situations
• “Price” of consent vs. refusal
• Patient inconsistency
• Disagreement among treatment team, family, etc. 

Suicidality

• Investigating suicidality - patient's subjective report in context of
• Their history
• Other behavioral indicators
• Credible collateral history (when available)
• Questions to ask
• Passive SI vs. active SI with intent/plan, e.g. "Do you think of hurting/killing yourself/feel the world would be better without you"; "Have you thought about how you would kill yourself", etc.
• Access to means - firearms, hanging, prescriptions
• Protective factors - family, community, religion
• If patient has SI
• Closer observation (sitter), elopement protocols
• Suicide risk assessment - psych eval