Do Consultation Psychiatrists, Forensic Psychiatrists, Psychiatry Trainees, and Health Care Lawyers Differ in Opinion on Gray Area Decision-Making Capacity Cases? A Vignette-Based Survey

Abstract

Background: Previous research in the area of medical decision-making capacity has demonstrated relatively poor agreement between experienced evaluators in "gray area" cases. We performed a survey to determine the level of agreement about gray area decision-making capacity case scenarios within and between individuals of different professional backgrounds.

Method: Participants received a survey consisting of 3 complicated decision-making capacity vignettes with an accompanying "yes/no" question regarding capacity and a certainty scale for each vignette. Participants were identified from mailing lists of professional organizations and local hospitals. We received responses from psychiatry trainees, consultation-liaison psychiatrists, forensic psychiatrists, and lawyers with experience in health care law. Results were analyzed using SPSS.

Results: Across the 3 vignettes, the percentage agreeing that the individual described had capacity to refuse medical treatment ranged between 35% and 40% for trainees, 33% and 67% for consult psychiatrists, 41% and 76% for forensic psychiatrists, and 40% and 83% for health care lawyers. Only question 2 reached significance between-group differences (Pearson χ(2) = 11.473, p < 0.01). Across vignettes, trainees were less likely to consider patients to have capacity for decision-making than were forensic psychiatrists and lawyers.

Conclusions: As found in previous research, agreement among experienced evaluators appears generally low in gray area capacity cases. It is noteworthy that individuals of different professional backgrounds at times offer divergent between-group opinions on capacity.

Keywords: capacity determinations.; decision-making capacity; forensic psychiatrists.