What is required for a doctor to document a patient's competence to make medical or financial decisions?

Documenting Patient Decision-Making Capacity

To document a patient's competence to make medical or financial decisions, doctors must assess and document four key abilities: understanding, appreciation, reasoning, and communication of choice. 1 This structured assessment is essential for establishing valid informed consent and protecting patient autonomy.

Core Components of Capacity Documentation

1. Assessment of Four Essential Abilities

• Understanding: Document that the patient can explain in their own words:

  • Their medical condition
  • The proposed treatment/intervention
  • Alternative options
  • Risks and benefits of each option 1, 2

• Appreciation: Document that the patient:

  • Acknowledges their medical condition
  • Recognizes consequences of decisions
  • Applies information to their personal situation 1

• Reasoning: Document the patient's ability to:

  • Compare options using personal values
  • Provide logical reasons for their choice
  • Demonstrate consistent reasoning process 1

• Communication: Document that the patient can:

  • Clearly express their decision by whatever means (verbal, sign language, or established code) 2

2. Decision-Specific Documentation

• Document that capacity was assessed specifically for the decision at hand, as capacity is decision-specific 2
• Note that capacity assessment should be proportionate to the risks involved in the decision 1
• Document that capacity was reassessed if needed, as it may fluctuate over time 1

Legal Standards and Jurisdictional Considerations

Different jurisdictions have varying legal frameworks for capacity assessment. Documentation should reflect awareness of the applicable legal standards:

• England and Wales: Document assessment of the patient's ability to understand information, retain it, use/weigh it, and communicate their decision (Mental Capacity Act 2005) 2

• Scotland: Document assessment of the patient's ability to act, make decisions, communicate decisions, understand decisions, and retain memory of decisions (Adults with Incapacity Act 2000) 2

• Other jurisdictions: Document according to local legal requirements

Common Pitfalls to Avoid in Documentation

• Avoid global determinations: Document that assessment was decision-specific rather than making sweeping judgments about overall competence 2
• Don't rely solely on cognitive tests: Document that capacity assessment went beyond standardized cognitive screening tests 1
• Presumption of capacity: Document that the adult patient was presumed to have capacity until demonstrated otherwise 1
• Diagnostic assumptions: Document that diagnosis of dementia or psychiatric illness alone was not used to determine lack of capacity 1
• Support measures: Document any steps taken to support the patient's decision-making before determining lack of capacity 1

Documentation for Patients Lacking Capacity

If a patient is determined to lack capacity, documentation should include:

• The specific abilities the patient lacks
• Identification of the appropriate surrogate decision-maker according to jurisdiction's laws 1
• Evidence that the surrogate's decisions align with:
  • Previously stated treatment preferences
  • Substituted judgment
  • The patient's best interests 1

Practical Documentation Approach

1. Document the context: Clinical situation requiring decision-making
2. Document information provided: What was explained to the patient
3. Document patient's responses: How they demonstrated understanding, appreciation, reasoning, and choice
4. Document conclusion: Clear statement about capacity determination
5. Document next steps: If capacity is present, document consent; if absent, document surrogate process

By following this structured approach to documenting capacity assessments, physicians can ensure they meet ethical and legal requirements while protecting patient autonomy and ensuring appropriate medical decision-making.