How to document a patient's lack of capacity to make medical decisions due to confusion?

Documentation of Patient's Lack of Capacity Due to Confusion

When documenting a patient's lack of capacity to make medical decisions due to confusion, you must clearly record the specific grounds for this determination, including evidence of cognitive impairment and how it affects the patient's decision-making abilities.

Assessment and Documentation Requirements

• Begin by documenting that capacity was initially assumed (as legally required) until proven otherwise through specific assessment 1, 2
• Document evidence of the patient's impairment or disturbance in mental functioning that affects decision-making, including specific examples of confusion 2
• Record your assessment of 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 in the decision-making process
  • Communicate their decision 2, 3
• Include specific examples demonstrating how confusion impacts each of these abilities 2, 4

Specific Documentation Elements

• Document concrete examples of confusion and how they directly impact decision-making capacity (avoid vague statements like "patient confused") 2, 5
• Record consultation with family members, friends, or other healthcare providers who can provide insight into the patient's baseline cognitive function 2
• Note that capacity is decision-specific - clearly identify which particular decisions the patient cannot make (avoid global assessments of incapacity) 2, 6
• Document that the patient's inability to make decisions is due to an impairment in the functioning of their mind or brain 1

Decision-Making Process Documentation

• Identify and document the authorized surrogate decision-maker 2
• Record any advance directives, lasting power of attorney, or court-appointed deputies that were reviewed 2, 1
• Document discussions with the surrogate about the patient's previously expressed wishes, values, and preferences 2
• Record your clinical reasoning that led to the determination that the patient lacks capacity 2
• Document that decisions made on behalf of the patient are in their best interests 1, 2

Avoiding Common Pitfalls

• Do not base capacity assessment solely on the patient's diagnosis, age, or appearance 1, 2
• Remember that a patient should not be treated as lacking capacity merely because they make an unwise decision 1
• Document that all practicable steps to support the patient's decision-making were taken before determining lack of capacity 1
• For temporary confusion, include plans for reassessment when the condition may improve 2, 7
• Document any disagreements between healthcare team members or family regarding the patient's capacity and how these were resolved 2

Legal and Ethical Considerations

• If the patient lacks capacity and no family members or close friends are available for serious medical treatment decisions, document consultation with an Independent Mental Capacity Advocate 1
• Record that the intervention or decision made on behalf of the person lacking capacity causes the least restriction of their rights and freedom of action 1
• Document that the best interests decision considers the patient's welfare in the widest sense - not just medical but social and psychological aspects 1