Determining the decision-making capacity of a patient who refused food and water

A terminal patient expressed the wish to hasten her death and refused nutrition. The psychiatrist asked to render an opinion relevant to her competence employed questions in a semi-structured interview derived from a new instrument originally designed to determine competence to create 'Advance Directives'. Although the patient ultimately demonstrated her resolve by totally ceasing fluid intake, the complexity of the case--including the question of the stability of her choice--illustrates the need for specific patient safeguards.