7
Fitzgerald Health Education Associates, Inc., August 2015 fhea.com
Certification Q&A;
ment Tools for Treatment (MacCAT-T )
5
and the Ca-
pacity to Consent to Treatment Instrument (CCTI).
6
Documentation
Clinicians must thoroughly document in the patient
record the details from the assessment interview
and the reasoning underlying their final determina-
tion regarding capacity. Documentation should in-
clude a short summary of the questions asked as
well as the patient's answers and decision.
4
Any for-
mal assessment tools used should also be recorded.
Conclusion
When a patient is found to lack capacity for making
decisions, a surrogate decision maker must be iden-
tified. Resources that can be used when addressing
the issue of surrogacy include existing advance di-
rectives and healthcare proxies, such as durable
power of attorney for family members.
2
•
References
1
. Ganzini L, Volicer L, Nelson WA, Fox E, Derse RA. Ten
myths about decision-making capacity. J Am Med Dir Assoc.
2004;5(4):263-267. www.ethics.va.gov/docs/necrpts/nec_
r
eport_20020201_ten_myths_about_dmc.pdf.
2. Dastidar JG, Odden A. How do I determine if my patient
h
as decision-making capacity? The Hospitalist. August 2, 2011.
www.the-hospitalist.org/article/how-do-i-determine-if-my-
patient-has-decision-making-capacity/?singlepage=1.
3. Tunzi M. Can the patient decide? Evaluating patient capacity
in practice. Am Fam Physician. 2001;64:299-306.
4. Klein CA. Decision-making capacity and informed consent.
Nurse Pract. 2005;30:12. http://journals.lww.com/tnpj/Cita-
tion/2005/02000/Decision_Making_Capacity_and_Informed_
Consent.3.aspx.
5. Grisso T, Appelbaum PS, Hill-Fotouhi C. The MacCAT-T: a
clinical tool to assess patients' capacities to make treatment de-
cisions. Psychiatr Serv. 1997;48(11):1415-1419.
6. Moye J, Karel MJ, Azar AR, Gurrera RJ. Capacity to consent to
treatment: empirical comparison of three instruments in older adults
with and without dementia. Gerontologist. 2004;44(2):166-175.
C
ontinued from page 5
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