3.10 Decisional Capacity Determinations in Consultation-Liaison Psychiatry
In this high-yield episode of Psychiatry Boot Camp, Dr. Mira Zein (Associate Professor of Psychiatry and Behavioral Science at Stanford University) walks us through the nuances of decisional capacity assessment, a vital skill for anyone practicing in consultation-liaison (C-L) psychiatry.
If you're a medical student, intern, resident, or C-L psychiatrist, this episode is your go-to guide to truly understanding capacity—and how to assess it effectively using the Appelbaum-Grisso criteria. Whether you're fielding capacity consults in the hospital or guiding primary teams through tough calls, this episode equips you with the tools and confidence to do it well.
🧠 What You’ll Learn in This Episode:
✔️ A practical deep dive into the Appelbaum-Grisso model:
• Communicating a choice
• Appreciating the situation and consequences
• Understanding relevant information
• Reasoning with that information
✔️ When and why capacity questions are triggered in the hospital setting
✔️ Key clinical red flags that suggest impaired decision-making
✔️ The importance of decision-specific and time-specific evaluations
✔️ How to document decisional capacity in a legally sound, clinically clear manner
✔️ Strategies for fielding challenging consults from primary teams
✔️ How to handle capacity in the context of delirium, psychosis, trauma, and cognitive disorders
✔️ Navigating difficult conversations and interdisciplinary dynamics
📌 Why This Episode Matters:
Capacity determination is not just a checkbox; it’s a core ethical and clinical duty. A clear, structured approach prevents both overriding autonomy and failing to protect vulnerable patients. In fast-paced clinical environments—especially inpatient medical and surgical units—the psychiatrist is often the go-to expert for guidance.
But as Dr. Zein explains, non-psychiatrists can and should assess capacity too. This episode empowers not just specialists, but every clinician.
🔍 Key Resources Discussed:
APA Resource Document (2019): Decisional Capacity in C-L Psychiatry
Seminal Article (Appelbaum 1988): Assessing Patients’ Capacities to Consent to Treatment
Diagrammatic Interpretation of Capacity Framework (Bari 2023): A visual tool for clinicians
👨⚕️ Who Should Watch:
• Psychiatry residents, interns, and fellows rotating through C-L
• Internal medicine and surgery teams consulting psychiatry
• Emergency department physicians and hospitalists
• Hospital ethics committee members
• Nurse practitioners and PAs managing complex inpatients
• Legal-medical interface professionals
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💬 Comment Prompt for Engagement:
Have you ever been involved in a complex capacity case? What criteria or frameworks helped guide your clinical judgment?
📌 Suggested Timestamps:
00:00 – Introduction to Dr. Mira Zein
02:45 – Defining Capacity vs. Competence
06:20 – Appelbaum-Grisso Criteria Explained
11:40 – Clinical Scenarios Triggering Consults
16:30 – Tips for Documentation and Risk Management
21:00 – Primary Team Collaboration Tips
26:00 – Final Clinical Pearls for Medical Teams
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