To improve provider knowledge of the construct of capacity, clarify existing capacity
assessment institutional policies, and provide recommendations for conducting capacity
A semi-structured interview script and Likert scale survey were developed to investigate
stakeholder knowledge and perspectives on decision-making capacity. Constant Comparative
Method Analysis was conducted to identify themes across and within stakeholder groups.
Inpatient Rehabilitation Hospital.
Multidisciplinary stakeholder representatives, including physicians, investigators,
hospital administrators, legal counsel, psychologists, case managers, nurses, social
workers, caregivers, and patients (N=21), selected by the investigators using purposive
Main Outcome Measures
Four thematic areas (i.e. clinical, research, ethical, legal) identified through application
of a data reduction procedure.
Ethically, capacity assessment promotes patients’ autonomy, dignity, best interests,
well-being, values, preferences and goals of care, and allows patients to maintain
the right to refuse treatment. Clinically, stakeholders reported that capacity assessment
ensures that patient preferences are considered in the plan of care and that unwanted
procedures and treatments are prevented. Legally, capacity assessment ensures there
is valid informed consent. For research, capacity assessment helps establish a point
person to make decisions and allows for decisions to be made regarding patient participation
in research studies.
Providers identified challenges including lack of time, lack of familiarity with legal
statutes, and uncertainty about the multidimensionality of capacity. Investigators
identified challenges including tracking proxy/guardian status long-term and lack
of consensus between clinical and research teams. Surrogate decision makers identified
challenges including lack of direct contact with patients, family discord, and negative
impact of personal emotions. For healthcare systems, challenges included incomplete
medical records, high staff turnover, and team miscommunication.
A provider toolkit for capacity assessment and monitoring was developed based on challenges
identified by stakeholder groups and recommendations were proposed for refining institutional
policy and procedures.
While stakeholder groups appear to have a general understanding of the concept of
capacity, familiarity with specific procedures and regulations is limited. Institutions
should provide supportive resources for providers directly involved in assessment
of decision-making capacity.