In this episode, I sit down with Dr. Mira Zein, clinical associate professor at Stanford and co-author of the APA Resource Document on Decisional Capacity Determinations, to break down one of the most frequent and misunderstood consults in psychiatry.

We go deep into the Appelbaum–Grisso criteria and discuss how they apply to real-world cases where the answer isn’t always clear. Dr. Zein walks us through difficult scenarios, from life-saving refusals to medically complex delirium cases, highlighting how to think, document, and communicate clearly when capacity is in question. This episode will help you shine on rounds, guide your primary team through their own assessments, and remind you that capacity isn’t about saying “yes” or “no”, it’s about respecting autonomy while protecting patients at their most vulnerable.

Takeaways:
Capacity is decision-specific and time-specific. It’s not a global judgment, and it can fluctuate with illness, treatment, or environment.

The Appelbaum–Grisso framework defines the process. Every evaluation should include communication, understanding, appreciation, and reasoning.

Primary teams can and should do their own assessments. Psychiatrists are consultants, not gatekeepers; the best work happens through collaboration.

Delirium, dementia, and psychosis are common culprits. Each affects different aspects of capacity, requiring tailored interventions and re-evaluation.

Documentation is key. Define the specific decision, describe your assessment of each criterion, and explain your reasoning clearly for the record.

Key resources:
1) ⁠APA Resource Document on Decisional Capacity Determinations in Consultation-Liaison Psychiatry: A Guide for the General Psychiatrist⁠ (2019)
2) ⁠Seminal Article on Appelbaum-Grisso Criteria⁠ (Appelbaum 1988)
3) ⁠Evaluating Capacity: Appelbaum’s Framework Interpreted Diagrammatically⁠ (Bari 2023)

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Chapters:
00:00 Introduction to Decisional Capacity
01:05 Guest Introduction: Dr. Mira Zane
02:08 Importance of Capacity Consults
03:11 Fielding a Capacity Consult
04:17 Understanding Capacity Assessments
06:14 Common Reasons for Capacity Consults
07:45 Decisional Capacity Criteria
10:56 Communicating a Consistent Choice
15:21 Assessing Understanding and Appreciation
20:15 Evaluating Rational Thought Process
23:22 Edge Cases in Capacity Assessments
27:47 Evaluating Patient Capacity
29:14 Comprehensive Approach to Capacity Assessment
30:44 Standardized Instruments in Capacity Assessment
31:59 Common Disorders Affecting Capacity
33:41 Decisional vs. Dispositional Capacity
37:56 Post-Assessment Recommendations
41:26 Forensic Psychiatry and Capacity
45:15 Communicating Capacity Findings
50:32 Final Thoughts on Capacity Assessments
54:36 Podcast Conclusion and Credits