| DIALOG/PROGRESS NOTE TEXT |
Do not proceed before determining whether the patient has the capacity to
1. Understand the relevant information;
2. Appreciate the situation and its consequences;
3. Reason about treatment options;
4. Communicate a choice.
For all patients who are suspected of lacking decision-making capacity,
make decisions about life-sustaining treatments. Decision-making capacity
the practitioner must ensure that a clinical assessment of the above is
documented in the patient's health record.
If a patient lacks capacity to make decisions about life-sustaining
treatment and the surrogate is responsible for making those decisions,
the patient should, to the extent possible, be included in the goals of
care conversation.
is a clinical judgment about a patient's ability to make a particular
health care decision at a particular point in time. In clinical practice
(and law), the decision-making capacity of an adult patient is generally
presumed; however, when the patient's medical condition or observed
behavior raises questions about the patient's decision-making capacity,
the responsible practitioner must make an explicit determination based on
assessment of the patient's ability to do all of the following:
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