Assessing decision-making capacity in clinical practice in Norway: a qualitative exploration of stakeholder perspectives.

Background: Decision-making capacity (DMC) is a widely used criterion in health law, but assessments pose challenges in practice. In Norway, lacking DMC became an additional criterion for involuntary care and treatment following comprehensive amendments to the Mental Health Care Act in 2017. Contrary to the amendments' objectives, involuntary care rates have continued to increase after an initial reduction in 2017. Assessing DMC typically involves four abilities: understanding, reasoning, appreciating relevant information, and communicating a choice. This four abilities model was introduced to aid in DMC assessments. With limited assessment experience pre-2017, the Norwegian context offers valuable insights into how stakeholders integrate DMC into clinical practice over time. This study aimed to explore how DMC was assessed in clinical practice following the introduction of a capacity-based mental health law governing involuntary care and treatment in Norway.

Methods: In 2018, semi-structured interviews and focus groups were conducted with 44 key stakeholders, including psychiatrists, specialists in clinical psychology, general practitioners, and lawyers in supervisory bodies (the Control Commission and County Governor). In 2022-23, 21 of these participants took part in individual follow-up interviews. The interviews were transcribed and thematically analysed.

Results: Data analysis generated three themes with subthemes: (1) DMC assessments primarily relied on the four abilities model in specialist care, experiencing gradual clinical adaptation with decreased importance, and exhibited variations in quality, particularly in primary care; (2) several challenges in DMC assessments, including lack of training in applying the four abilities model, ownership, continuity of care, information, and patient cooperation, with certain patient groups posing particular challenges, such as those with manic symptoms, substance misuse, and severe eating disorders; and (3) quality assurance measures needed, including systematic training and tools to improve assessment quality.

Conclusions: Assessing DMC involves variations and several challenges across the healthcare system. While the four abilities model served as a primary basis of DMC assessments in specialist care, systematic training, validated tools, and further research seem needed to improve assessment quality and better understand factors influencing assessments. Recognising the complex interplay between legal, health service, and societal factors when implementing health law reforms seems crucial for achieving their objectives.