Competency is declared by a court, not a physician.

Clinical assessment of capacity to make treatment decisions is sometimes called “competency evaluation,” though this is technically incorrect.

Capacity can be global or task specific.

Evaluating the capacity to make treatment decisions requires the following information:

Factual understanding of the information.

Appreciation of the seriousness of the condition and consequences of accepting or rejecting treatment.

Ability to manipulate the information in a rational fashion and come to a decision logically.

Communication of a preference.

Emergency situations when failure to provide treatment may result in serious damage.

The patient’s waiver for decision making, which usually implies trust in someone else’s judgment.

Therapeutic privilege. The physician has therapeutic privilege when the process of obtaining consent is judged harmful to the patient. This usually means not a complete exemption, but a deferred process.

The psychiatrist should keep a separate set of process notes, which are his or her personal property rather than the property of the institution.

Competent individuals have a right to make their own treatment decisions, including refusal of treatment that others believe is in their best interest.

When a patient is deemed incapacitated and unable to make treatment decisions, an alternative decision maker should be sought.

Decisions on routine and ordinary care may be made by family members who know the patient well.

Decisions on extraordinary, invasive, or dangerous procedures should be made by a guardian.

Depending on state laws, some extraordinary treatments may require court authorization.

Allowing an incapacitated patient to continue making treatment decisions is unethical.

No. Both organizations consider this behavior to be unethical, and maintain that psychiatrists should not participate in executions.

The basic principle of boundary is that the physician is obligated to put the best interests of the patient ahead of the physician’s interests. Any behavior that may favor the physician’s interests over the patient’s interests may cause boundary violations.