Decision Making Capacity
Decision making capacity assessment is done in an adult who does not have a legal guardian.
When assessing for "competency," please note the following issues in your notes:
Does the patient understand the nature of his/her condition and the treatment(s) being recommended?
Does the patient understand the consequences of choosing or refusing those therapies at the time of your discussion?
Can the patient rationally consider the information to compare benefits and risks in an organized fashion?
Is the patient able to make and communicate his/her choices?
The answers to above questions should be recorded in the patient's "own words" as evidence.
Procedures need to be explained to the patient in a language that he/she understands.
Ask the patient to repeat his/her understanding of the discussion.
Identify and address the patient's misperceptions and fears.
When appropriate and available, involvement of family and friends is encouraged.
This is a recommended minimum requirement to be documented in the chart for "competency" assessments; please avoid using the word competent or incompetent in your notes. The note should read something like: "Based on the above findings, it is my clinical opinion that this patient is (or is not) able to fully participate in decision making about his/her medical care at this time."
For transient conditions (e.g., delirium), if there is no urgency to the situation, consider revisiting the issue at a later time following treatment. For more permanent conditions (e.g., Alzheimer's), recommended legal guardianship be pursued, even if on a temporary basis.
If a patient has executed an Advanced Directive or Durable Power of Attorney, document that a surrogate decision maker needs to be consulted.