Assessment of Decisional Capacity: Guidelines, Ethics, and Evidence with Dr. Mira Zein

In this episode, I sit down with Dr. Mira Zein, clinical associate professor at Stanford and co-author of the APA Resource Document on Decisional Capacity Determinations, to break down one of the most frequent and misunderstood consults in psychiatry.
We go deep into the Appelbaum–Grisso criteria and discuss how they apply to real-world cases where the answer isn’t always clear. Dr. Zein walks us through difficult scenarios, from life-saving refusals to medically complex delirium cases, highlighting how to think, document, and communicate clearly when capacity is in question. This episode will help you shine on rounds, guide your primary team through their own assessments, and remind you that capacity isn’t about saying “yes” or “no”, it’s about respecting autonomy while protecting patients at their most vulnerable.

Takeaways:

Capacity is decision-specific and time-specific. It’s not a global judgment, and it can fluctuate with illness, treatment, or environment.
The Appelbaum–Grisso framework defines the process. Every evaluation should include communication, understanding, appreciation, and reasoning.
Primary teams can and should do their own assessments. Psychiatrists are consultants, not gatekeepers; the best work happens through collaboration.
Delirium, dementia, and psychosis are common culprits. Each affects different aspects of capacity, requiring tailored interventions and re-evaluation.
Documentation is key. Define the specific decision, describe your assessment of each criterion, and explain your reasoning clearly for the record.

Key resources:

1) APA Resource Document on Decisional Capacity Determinations in Consultation-Liaison Psychiatry: A Guide for the General Psychiatrist (2019)

2) Seminal Article on Appelbaum-Grisso Criteria (Appelbaum 1988)

3) Evaluating Capacity: Appelbaum’s Framework Interpreted Diagrammatically (Bari 2023)

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