Decisional Capacity in Psychiatric Inpatient Settings: Understanding and Addressing Key Barriers to Shared Decision Making

Abstract

Research indicates that the degree to which shared decision making (SDM) is implemented within inpatient care across the VHA varies significantly. International literature on this topic suggests that clinicians' concern around patients’ reduced decisional capacity is a frequently reported barrier to SDM implementation, yet determining decisional capacity for SDM is complex. To date, it is unclear how clinicians within the US are currently determining patients’ ability to participate in decisionmaking, particularly in situations when there is less certainty around this determination (e.g., concerns of reduced decisional capacity, acute symptoms, liability concerns). While solutions have been proposed, the literature remains divided on the best approach in adapting SDM to address these barriers, and none have been explicitly implemented within the United States. As such, the current study interviewed 25 acute mental health inpatient psychiatrists across 17 unique VHA sites to: 1) determine how psychiatric inpatient psychiatrists are determining patients’ ability to make medication management decisions and, 2) gather psychiatric inpatient psychiatrists’ perspectives on the perceived acceptability and adaptability of key elements proposed as possible solutions in the literature (i.e., capacity-adjusted sliding scale SDM, SDM-PLUS, Shared Risk Taking). Through emergent thematic analysis, the current study identified a complex relationship between risk, capacity, and mental health law that influences providers’ level of collaboration within medication management decisions. Further, providers indicated a preference for a combination of approaches to address reduced decisional capacity as a barrier to SDM. The current study proposes elements for future SDM interventions and future directions to further address reduced decisional capacity and facilitate SDM within acute mental health inpatient care.