Define capacity versus competence in decision-making, and how should a nurse assess it?

• A. Capacity is patient-specific and decision-specific; competence is a legal determination. Assess by evaluating understanding, appreciation of consequences, reasoning, and ability to communicate a choice; involve interdisciplinary teams when uncertain.
• B. Capacity equals legal status; competence is determined by the patient.
• C. They are the same concept; assess by asking the patient.
• D. Capacity is defined by age; competence is determined by physician.

Answer: (A)

Understanding decision-making ability hinges on recognizing that capacity is about the person’s ability to meet a specific decision at a specific time, while competence is a legal determination. Capacity means the patient can understand information relevant to the decision, appreciate how it applies to their own situation, reason about options, and communicate a choice. Because capacity is decision-specific and can change with context or over time, a nurse assesses it for the particular decision at hand rather than assuming it for all situations.

Competence, on the other hand, is a legal status determined by a court or designated authority. It isn’t something a nurse can assign or confirm; it’s about whether a person has the legal capacity to make decisions, which may involve guardianship or protective proceedings if incapacity is established. In clinical practice, focus is on capacity and supporting the patient to maximize it, recognizing when professional judgment or legal input is needed.

To assess capacity, evaluate four domains: understanding (can the patient grasp the essential information about the option and consequences?), appreciation (can they recognize how the information applies to their own situation and potential outcomes?), reasoning (can they compare options and weigh risks, benefits, and trade-offs?), and communication (can they consistently convey a clear and voluntary choice?). Be mindful of factors that can impair capacity temporarily, such as pain, delirium, sedation, language barriers, hearing or vision impairment, and cognitive impairment. When uncertainty exists about decision-making ability, involve interdisciplinary colleagues—physicians, social workers, or ethics teams—and document the assessment and rationale.