ity must be more carefully assessed whenever a pa-
tient undergoes a hospital or outpatient procedure
and for routine care when there are strong reasons
to question a patient's decision-making ability. A
number of conditions can compromise decision-mak-
ing capacity, including delirium, dementia, psychi-
atric disorders, trauma, pain, medication effects, and
intoxication.
4
A patient's capacity to make healthcare
decisions can fluctuate over time, depending on his
health status and other factors, and should be as-
sessed more than one time. When a patient's lack of
capacity is considered to be temporary, periodic re-
assessments should be conducted and important de-
cisions should be delayed, if possible, while the un-
derlying illness is being treated.
1
At the same time, a
patient who is disoriented to time or location is of-
ten still capable of making an informed decision if he
or she can demonstrate the four abilities outlined
here. When delay is not possible, a surrogate deci-
sion maker should be selected, with the patient's au-
thority for decision making restored once he or she
recovers.
When is a formal assessment recommended?
In most cases, it is sufficient for clinicians to under-
stand the four components of decision-making ca-
pacity and be able perform a directed clinical inter-
view regarding them. Use of a formal assessment
tool, in addition to the clinical assessment, should
be considered when capacity is uncertain, surro-
gate decision-makers do not agree, or judicial in-
volvement is anticipated.
3
Several instruments that
have been used for conducting structured assess-
ment include the MacArthur Competence Assess-
C
ontinued from page 3
Certification Q&A;
Continued on page 7