DECISION-MAKING CAPACITY ASSESSMENT

Decision-Making Capacity Assessment


This assessment is evaluating the Patient's capacity to make a specific 
decision about which of the following?
  Naming or updating a surrogate for healthcare decisions


    What diagnostic concern is triggering the capacity assessment?
      Brain injury including recent neurosurgical procedures
      Mental illness
      Cognitive impairment
      Delirium
      Substance related or induced impairment (ie withdrawal or intoxication)
      Critical medical illness
      Other


    Patient's understanding of the role of a Health Care Surrogate:
    X


    Is the patient able to show an understanding of a Health Care Surrogate's 
    role?
      No
      
        Declined to answer

     

      Other relevant information (e.g., cultural or religious values, history, 
      or context):
        X


        ======================================================


      CONCLUSION:
        In my clinical judgement, the patient does have capacity to make the 
        following specific decision: 



        ======================================================


        This is not an assessment regarding the Patient's capacity to make all 
        decisions, in all circumstances, at all times. 
        The Patient may have the ability to make other specific decisions or 
        this decision at a different time.

      Recommend re-evaluation (e.g., time frame, circumstances).
      X


 Other relevant information (e.g., cultural or religious values, history, 
      or context):


        ======================================================


      CONCLUSION:


        ======================================================


        This is not an assessment regarding the Patient's capacity to make all 
        decisions, in all circumstances, at all times. 
        The Patient may have the ability to make other specific decisions or 
        this decision at a different time.
        Decision-Making Capacity Assessment


This assessment is evaluating the Patient's capacity to make a specific 
decision about which of the following?
  Revoking a surrogate for healthcare decisions


    What diagnostic concern is triggering the capacity assessment?
      Brain injury including recent neurosurgical procedures
      Mental illness
      Cognitive impairment
      Delirium
      Substance related or induced impairment (ie withdrawal or intoxication)
      Critical medical illness
      Other
        X
    Reasons the patient no longer wants current surrogate to make healthcare 
    decisions.
    X


    Is the patient able to show sound rationale?
      Yes


        Patient explanation of consequences of current surrogate no longer 
        making healthcare decisions.
        X

        Other relevant information (e.g., cultural or religious values, 
        history, or context):
          X


          ======================================================


        CONCLUSION:
          In my clinical judgement, the patient does not have capacity to make 
          the following specific decision: X


          ======================================================

        Recommend re-evaluation (e.g., time frame, circumstances).
        X
Decision-Making Capacity Assessment


This assessment is evaluating the Patient's capacity to make a specific 
decision about which of the following?
  Naming or updating a surrogate for healthcare decisions


    What diagnostic concern is triggering the capacity assessment?
      Brain injury including recent neurosurgical procedures
      Mental illness
      Cognitive impairment
      Delirium
      Substance related or induced impairment (ie withdrawal or intoxication)
      Critical medical illness
      Other
        X


    Patient's understanding of the role of a Health Care Surrogate:
    X


    Is the patient able to show an understanding of a Health Care Surrogate's 
    role?
      Declined to answer

      Other relevant information (e.g., cultural or religious values, history, 
      or context):


        ======================================================


      CONCLUSION:


        ======================================================


        This is not an assessment regarding the Patient's capacity to make all 
        decisions, in all circumstances, at all times. 
        The Patient may have the ability to make other specific decisions or 
        this decision at a different time.

Decision-Making Capacity Assessment


This assessment is evaluating the Patient's capacity to make a specific 
decision about which of the following?
  Appropriate level of care (including discharge planning)
    Specific level of care determination: X


    What diagnostic concern is triggering the capacity assessment?
      Brain injury including recent neurosurgical procedures
      Mental illness
      Cognitive impairment
      Delirium
      Substance related or induced impairment (ie withdrawal or intoxication)
      Critical medical illness
      Other
        X


    Does the Patient have the ability to communicate a clear choice?
      No
      Explain: X


        ======================================================


      CONCLUSION:
        In my clinical judgement, the patient does have capacity to make the 
        following specific decision: X


        ======================================================


        This is not an assessment regarding the Patient's capacity to make all 
        decisions, in all circumstances, at all times. 
        The Patient may have the ability to make other specific decisions or 
        this decision at a different time.
        This is not an assessment regarding the Patient's capacity to make all 
        decisions, in all circumstances, at all times. 
        The Patient may have the ability to make other specific decisions or 
        this decision at a different time.

      Recommend re-evaluation (e.g., time frame, circumstances).
      X
Decision-Making Capacity Assessment


This assessment is evaluating the Patient's capacity to make a specific 
decision about which of the following?
  Clinical treatment or procedure (including Against Medical Advice-AMA 
  decisions and LST decisions)
    Specific clinical treatment or procedure: X


    What diagnostic concern is triggering the capacity assessment?
      Brain injury including recent neurosurgical procedures
      Mental illness
      Cognitive impairment
      Delirium
      Substance related or induced impairment (ie withdrawal or intoxication)
      Critical medical illness
      Other
        X


    Does the Patient have the ability to communicate a clear choice?
      No
      Explain: X


        ======================================================


      CONCLUSION:
        In my clinical judgement, the patient does not have capacity to make 
        the following specific decision: 


        ======================================================


        This is not an assessment regarding the Patient's capacity to make all 
        decisions, in all circumstances, at all times. 
        The Patient may have the ability to make other specific decisions or 
        this decision at a different time.

      Recommend re-evaluation (e.g., time frame, circumstances).
      X


          This is not an assessment regarding the Patient's capacity to make 
          all decisions, in all circumstances, at all times. 
          The Patient may have the ability to make other specific decisions or 
          this decision at a different time.