Checklist for Capacity to Make Treatment Decisions

Checklist for Capacity to Make Treatment Decisions
Part 1:  Factual Understanding of Issues
[select name="Q1" value="satisfactory|marginal|unsatisfactory"] <-- What is wrong with you (or what illness do you have)?
[select name="Q2" value="satisfactory|marginal|unsatisfactory"] <-- What are the treatment or tests recommended for you? 
[select name="Q3" value="satisfactory|marginal|unsatisfactory"] <-- What are the treatments supposed to do for you?
[select name="Q4" value="satisfactory|marginal|unsatisfactory"] <-- What might happen with the treatment that you do not want to happen?
[select name="Q5" value="satisfactory|marginal|unsatisfactory"] <-- What else could be done for your illness/problem (pros/cons)?
[select name="Q6" value="satisfactory|marginal|unsatisfactory"] <-- You mentioned that your doctor told you about risks with treatment – how likely do you think it is that the risks might occur?
[select name="Q7" value="satisfactory|marginal|unsatisfactory"] <-- Why is your doctor giving you all this information?
Part 2:  Appreciation of Consequences
[select name="Q8" value="satisfactory|marginal|unsatisfactory"] <-- Explain what you believe is wrong with your health.
[select name="Q9" value="satisfactory|marginal|unsatisfactory"] <-- Do you believe you need treatment?  What is treatment likely to do for you?
[select name="Q10" value="satisfactory|marginal|unsatisfactory"] <-- What do you believe will happen if you are not treated?
[select name="Q11" value="satisfactory|marginal|unsatisfactory"] <-- Why do you think your doctor has recommended specific treatment for you?
Part 3:  Rational Manipulation of Information
[select name="Q12" value="satisfactory|marginal|unsatisfactory"] <-- Tell me how you reached the decision to accept or reject the recommended treatment?
[select name="Q13" value="satisfactory|marginal|unsatisfactory"] <-- What were the things that were important in reaching your decision?
[select name="Q14" value="satisfactory|marginal|unsatisfactory"] <-- How did you balance the pluses and minuses?
[textarea memo="Comments/Discussion"]
[checkbox memo="display/hide references" name="footnotes" value=""][conditional field="footnotes" condition="(footnotes).is('')"]
reference:  
[link url="//www.ncbi.nlm.nih.gov/pubmed/3200278" memo="#1"] Appelbaum PS, Grisso T. Assessing patients capacities to consent to treatment. N Engl J Med. 1988 Dec 22;319(25):1635-8.[/conditional]