Long-term, assenting psychiatric patients: decisional capacity and the quality of care

The objectives of this study were (1) to investigate whether the relationship between functional decisional capacity and the resulting quality of treatment posited by the informed consent theory is found in clinical practice; and (2) to describe the range of decisional impairments found in long-term psychiatric inpatients who comply with prescribed treatment. Eighty-eight long-term, compliant, psychiatric inpatients, in two public hospitals, who were prescribed antipsychotic medications were assessed. Following a formal assessment of decisional capacity, subjects were categorized according to level of impairment, using a hierarchical scheme. All subjects were evaluated for the presence of abnormal involuntary movements. The appropriateness of treatment with antipsychotic medications was determined using accepted clinical guidelines. Patients with more serious impairments of decisional capacity were more likely to receive inappropriate treatment with antipsychotic medication; and serious impairments of decisional capacity were common. The study lends empirical support to one of the bases of the doctrine of informed consent: the notion that capable patient involvement in decisionmaking plays an important role in checking the judgments of treating physicians. Remedial measures are needed to protect long-term psychiatric inpatients with impaired decisional capacity from receiving inappropriate treatment.