Archives of Psychiatry and Psychotherapy, 2008; 4 : 47–55 H. Russell Searight, Audrey Montooth: Department of Psycholo- gy, Lake Superior State University, USA; Correspondence address: H. Russell Searight, Associate Professor, Department of Psychology, Lake Superior State University, 650 W. Easterday Ave. Sault Sainte Marie, MI 49783, USA, e-mail: hsearight@lssu.edu Changes in decision making capacity during illness: a review and case report with implications H. Russell Searight, Audrey Montooth Summary Mental health professionals in general hospital settings are frequently asked to provide consultative opin- ions about patients’ capacity for medical decisions and self-care. Adult patients are assumed to be au- tonomous decision makers unless they have been determined to be incompetent through a judicial pro- ceeding. In reality, however, clinical judgements of incapacity are often accorded the status of law. Treat- ment, when seen as in the patient’s best interest, may proceed against the patient’s explicit wishes. In addition, capacity decisions are often viewed as fixed, enduing states even though many medical condi- tions adversely affecting decisional skills are reversible. Ms. Thornton, a 37-year-old woman, admitted for a ruptured cerebral aneurysm, underwent three capac- ity evaluations during her six week hospitalization. At the first two assessments separated by about two weeks, she demonstrated little understanding of her condition, treatment options, and likely outcomes with and without intervention. At the third assessment, six weeks after admission, Ms. Thornton had regained adequate decisional ca- pacity and was subsequently discharged. Clinicians conducting capacity evaluations in an era of brief hos- pitalization, with accompanying pressures to rapidly discharge patients, should include attention to both medical and psychiatric conditions, which when treated, lead to regained capacity. Decision-Making Capacity / Competence / Ethical Issues THEORETICAL AND RESEARCH BASIS Consultation requests centering around pa- tient competence are commonly received by general hospital psychologists and psychiatrists. Patients may be considered incapacitated when they exhibit “…functional deficits…judged to be sufficiently great that the person currently cannot meet the demands of a specific decision- making situation weighted in light of its poten- tial consequence” [1]. Capacity questions may be raised about the patient’s ability to live inde- pendently, make medical decisions, care for chil- dren or dependent adults, manage finances, and enter into legally binding contracts. While the current case focuses primarily on medical de- cision-making, treating physicians also sought opinions about capacities for independent liv- ing and parenting. Evaluations of patient’s medical decision-mak- ing capacity are typically triggered by one of the following situations [2]: 1) The patient initiates the process of signing out of the hospital against med- ical advice; 2) There is concern about the patient’s capacity to give informed consent for surgery, in- vasive tests, or other procedures; 3) There is con- cern about the patient’s ability to take appropri- ate health precautions and comply with follow-up care; 4) The patient is refusing medical treatment for potentially life-threatening condition.