The finding: This retrospective study reviewed one year of decision-making capacity (DMC) evaluations (n=167) at a large academic/tertiary care hospital. The study confirmed its hypothesis that “unwarranted” DMC requests were common (56.8%). “Warranted” DMC evaluations were driven by acute neuropsychiatric disturbances, which reflects the central role in examining fluctuating or unclear cognition. “Unwarranted” evaluations were requested by primary teams, without concern for a patient’s cognitive ability, for patients who obviously lacked capacity (given gross disorientation, delirium, coma, inability to communicate), or for global rather than task and time specific questions. Pre-existing psychiatric diagnoses appeared to compel DMC requests. Lastly, 11.6% of cases had explicitly documented ethical concerns, suggesting themes of clinical uncertainty, moral distress and defensive medicine as important contributing factors.

Strength and weaknesses: As stated, this study is strengthened by a large sample size, multiple variables assessed, and standardization of coders.

“Unwarranted”, poorly articulated, misstated or reductive DMC requests may still foster important clinical conversations between C-L psychiatry and the consulting services in navigating complex neuropsychiatric/psychosocial or ethical concerns. The retrospective chart review is unable to capture liaison/consultee conversations that naturally occur in the consult process and better articulate the original DMC request.

Relevance: Decision-making capacity evaluations are increasingly requested of consult psychiatry services. It is important to understand the underlying contributors to these DMC requests as we aim improve physician-patient relationships, communication and navigate complex psychosocial and ethical concerns in the hospital setting