From the Guidelines
When a patient loses decisional capacity, healthcare providers should first attempt to identify a surrogate decision-maker, such as a spouse, adult children, or other relatives, and make decisions based on substituted judgment or best interests, as recommended by the American Thoracic Society and American Geriatrics Society in 2020 1.
Key Considerations
- The loss of decisional capacity may be transient, and reversible causes such as delirium, infection, or sedating medications should be addressed before making important treatment decisions 1.
- Capacity is decision-specific, and patients may have partial capacity to make certain decisions, such as appointing a surrogate 1.
- In the absence of advance directives, a hierarchy of surrogate decision-makers should be followed, typically starting with spouse, followed by adult children, parents, siblings, and other relatives.
- For emergency situations where no surrogate is immediately available, providers should act in the patient's best interest to prevent harm.
Documentation and Communication
- All capacity assessments, surrogate identification processes, and decision-making discussions should be documented in the medical record 1.
- Establishing rapport and lines of communication with the family and identifying a spokesperson can facilitate the decision-making process 1.
- Consider ethics committee consultation for complex cases involving disagreements among potential surrogates or when the patient's wishes are unclear.
Regular Reassessment
- Capacity should be reassessed regularly, especially for major medical decisions, as patients may regain the ability to participate in some aspects of their care 1.
- Healthcare providers should be aware that the ability of critically ill patients to participate in decision-making often fluctuates over the course of their illness trajectory 1.
From the Research
Decisional Capacity
When a patient loses decisional capacity, it is essential to determine the best course of action to respect their autonomy and ensure their safety.
- The four-skills model of decisional capacity, developed by Appelbaum and Grisso, is widely used to assess a patient's ability to make informed decisions 2.
- However, in cases where a patient is at foreseeable risk of losing decisional and functional capacity, a more nuanced approach may be necessary 2.
Surrogate Decision-Making
If a patient lacks decision-making capacity, a surrogate decision-maker should be sought to make decisions on their behalf.
- The surrogate decision-maker may be a previously selected individual, such as a power of attorney, or a court-appointed deputy 3.
- The surrogate decision-maker should consider the patient's preferences, values, and best interests when making decisions 4, 3.
Patient Preferences
Patient preferences should be taken into account when making decisions about their care, even if they lack decision-making capacity.
- Research has shown that patients prioritize being treated consistent with their own preferences, minimizing the burden on their family, and involving their family in the decision-making process 5.
- Clinicians should discuss and document patients' priorities for decision-making during periods of incapacity 5.
Best Interests
When a patient lacks capacity, decisions should be made in their best interests.
- The Mental Capacity Act 2005 in England and Wales provides a framework for determining best interests, which involves considering the patient's wishes, feelings, and beliefs 3.
- A person-centred, flexible approach to best interests should be taken, involving family and friends in the decision-making process 3.