C-L Case Conference: Assessment of dispositional capacity in medically complex patients

We present the case of a 76 year old male with mild cognitive impairment and delirium referred to Consultation-Liaison Psychiatry for assessment of capacity to choose discharge. Cases involving “dispositional capacity” are complex and increasingly frequent, with momentous consequences for patients and their families, but rarely discussed in the literature. In this article, experts in functional assessment, cognition, and ethics provide guidance for this commonly encountered clinical scenario based on their experience and available literature. We review the content and formulation of occupational and physical therapy assessments and their utility to the CL psychiatrist. We also examine the relationship of cognitive impairment to decisional capacity and offer suggestions on a structured approach to evaluation. Finally, we discuss the ethical and systemic considerations of dispositional capacity and explore potential pitfalls that can lead to interprofessional conflict and missed opportunities in patient care.