Documentation of Patient's Inability to Make Decisions Due to Confusion

Assessment and Documentation of Capacity

The American Society of Anesthesiologists assumes that capacity is present initially, as required by law, until proven otherwise through specific assessment, which includes documenting evidence of the patient's impairment or disturbance in the functioning of their mind or brain that affects decision-making 1, 2
The assessment of decision-making capacity should include evaluating the patient's ability to understand relevant information about the decision, retain that information long enough to make the decision, use or weigh that information as part of the decision-making process, and communicate their decision by any means, as recommended by the American College of Gastroenterology 1, 2, 3

The patient's confusion and its impact on their ability to make a particular decision should be documented, including specific examples, as suggested by the American Society of Anesthesiologists 1, 4
Consultation with family members, friends, or other healthcare providers who can provide insight into the patient's baseline cognitive function should be documented, as recommended by the Society of Critical Care Medicine 5, 6

The authorized surrogate decision-maker should be identified and documented, along with any advance directives, lasting power of attorney, or court-appointed deputies that were reviewed, as recommended by the American Society of Anesthesiologists 1, 7
Discussions with the surrogate about the patient's previously expressed wishes, values, and preferences should be documented, as suggested by the Society of Critical Care Medicine and the European Society for Clinical Nutrition and Metabolism 5, 7
The clinical reasoning that led to the determination that the patient lacks capacity should be documented, along with the fact that decisions made on behalf of the patient are in their best interests, as recommended by the American Society of Anesthesiologists and the European Society for Clinical Nutrition and Metabolism 1, 4, 8

The patient's capacity should not be assessed based solely on their diagnosis, age, or appearance, as cautioned by the American Society of Anesthesiologists 1, 4
Vague statements like "patient confused" should be avoided without specific examples, and a global assessment of incapacity should not be documented without specifying which decisions the patient cannot make, as recommended by the American Society of Anesthesiologists 1, 9

For temporary confusion, plans for reassessment of capacity when the condition may improve should be documented, as suggested by the American Society of Anesthesiologists 1, 4
Disagreements between healthcare team members or family regarding the patient's capacity and how these were resolved should be documented, as recommended by the European Society for Clinical Nutrition and Metabolism and the Society of Critical Care Medicine 6, 7

The American Academy of Periodontology recommends that the assessment of competence for testamentary capacity should include understanding, appreciation, reasoning, and expression of choice 10, 11, 12
Understanding refers to the ability to comprehend basic information, including the nature of one's condition and the consequences of decisions 10, 11
Appreciation involves recognizing one's medical condition and the likely consequences of one's decisions 10, 12
Reasoning is the ability to weigh risks and benefits and make a decision consistent with this evaluation 10, 12
Expression of choice refers to the ability to express a decision indicating a preferred option 12

A score of 26/30 on the Mini-Mental State Examination (MMSE) indicates preservation of basic cognitive functions 13
Despite physical limitations, individuals can retain the ability to make independent decisions if their cognitive functions are preserved 10, 14

Competence is decision-specific and not a global characteristic 10, 14
A modern approach to competence assessment recognizes that individuals may retain the ability to make certain decisions even if they have lost the ability to make others 10