Capacity assessment for surgical refusal after psychosis (MEQ)

(i) Definition and abilities. Decision-making capacity is a decision- and time-specific clinical judgment about whether a person can make this treatment choice now — not a global status derived from diagnosis. The four functional abilities (Appelbaum/Grisso) are: understand relevant information; appreciate the situation and consequences as applied to oneself; reason (use or weigh) options; and communicate a choice. Statute language in some jurisdictions maps to understand, retain, use or weigh, and communicate. Legal competence may refer to formal court/tribunal determinations; clinicians assess capacity at the bedside.^[1][2][4]

(ii) Assessment structure. Define the decision (appendicectomy now). Optimise setting (quiet, interpreter if needed, minimise sedation). Disclose material information: nature of appendicitis, proposed surgery, benefits, material risks, alternatives including antibiotics-only/no treatment and likely consequences. Probe each ability with teach-back; explore whether the tracking-device belief blocks appreciation despite intact factual recitation. Offer supports; consider whether antipsychotic treatment and time could restore capacity if delay is surgically acceptable. Document information given, ability-by-ability findings (with quotes), conclusion, and review time. MacCAT-T concepts can structure the interview without treating a score as a legal verdict.^[2][3][5]

(iii) Mental health vs capacity pathways. Mental health legislation typically authorises compulsory psychiatric assessment/treatment when statutory mental disorder and risk (or equivalent) criteria are met, with least-restrictive principles — criteria and processes are jurisdiction-specific (do not invent section numbers). Capacity/consent and guardianship frameworks govern general medical decisions when the person lacks capacity. Detention for psychiatric care does not automatically authorise surgery. Both pathways may be relevant in one admission for different decisions.^[2][4]

(iv) Management branches. If capacity present: respect informed consent or informed refusal; document carefully; senior medical/surgical discussion of residual risk. If capacity absent: if life/limb-threatening and cannot wait, emergency treatment under necessity/statutory emergency provisions with documentation; if delay is safe, treat psychosis and reassess; if decision needed and capacity remains absent, use lawful substitute decision-maker or best-interests process under local law, incorporating past wishes and least restrictive option. Consider whether mental health pathways are separately indicated for psychiatric treatment.^[2][4]

(v) Evidence anchors. Appelbaum and Grisso abilities framework and Appelbaum 2007 NEJM clinical practice review; MacCAT-T (Grisso et al.); Owen et al. on diagnosis/insight and capacity in psychiatric inpatients; Buchanan on capacity, legal competence, and consent.^[1][2][3][5]