Receiving a well thought out documentation phrase from a fellow clinician is almost as amazing as getting a pet chupacabra for your birthday. What I love about documentation phrases (aka smart-phrases, dot-phrases, Dragon commands, etc) is that they provide a structured checklist of things to remember, add flow to the chart, and, best of all, save time. I’ve made, mutated, and straight-out stolen some gems over the years. Today I want to discuss one of my all-time favorites: Decision-Making Capacity.
Below is the preset dot-phrase that I used to remind myself of all of the aspects of decision-making capacity that needed to be met before I could say, “It’s okay that this person disagrees with me.”
I feel that the patient has decision-making capacity. [He/She] demonstrates the ability to understand the current situation and is able to communicate a choice for what [he/she] wants to do. [He/She] expresses understanding of benefits, risks, and alternatives and is able to make logical and rational choices, even though they are not in line with my recommended medical direction. There is no evidence of intoxication or altered mentation which would preclude normal cognitive function.
When I used this phrase in medical decision-making, it was critically important that it include a description of the current situation, family involvement in conversations, risks discussed, and alternatives offered. The dot-phrase by itself doesn’t supplant the specific narrative for the patient in question.
We all have had patients who disagreed with our plan of care. Whatever the reason, we needed to know if they had the capacity to understand what they were declining, and then we needed to document it. For someone to have decision-making capacity, all of the following need to be met (from ACEP QI Update):
- Ability to understand information relevant to treatment decisions.
- Ability to appreciate the significance of the information.
- Ability to weigh treatment options and demonstrate reasoning.
- Ability to express a choice.
It sounds so easy to do, just check off the boxes. But there is nuance wrapped in complexity shrouded in uncertainty when it comes to sorting out whether or not some patients have capacity. For example, does an involuntarily committed patient have capacity? What about someone with underlying mental illness? To learn more about this, read Ten Myths About Decision Making Capacity. How about the patient with dementia? Check out the pearls on this subject in Measuring Decision-Making Capacity in Cognitively Impaired Adults. Finally, a 2016 ACEP QI newsletter has good scripting on how to walk through the process.
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