Capacity-to-Consent Decision Aid

Clinical Decision Support Tool

Clinical Pearl: Capacity is decision-specific and can fluctuate over time. This tool assists with systematic assessment but does not replace clinical judgment. Capacity is presumed in adults unless evidence suggests otherwise.

Patient Information (Optional)

Patient Name

Assessment Date

Medical Decision Context

1. Understanding

Can the patient comprehend information about their medical condition and treatment options?

Assessment Questions:

Can the patient repeat back their diagnosis in their own words?
Do they understand the nature and purpose of the proposed treatment?
Can they describe the risks and benefits of treatment options?
Do they understand the consequences of refusing treatment?

Clinical Observations and Notes

Understanding Assessment

Met Patient demonstrates adequate understanding Not Met Patient does not demonstrate adequate understanding Unclear Further assessment needed

2. Appreciation

Does the patient recognize that the medical information applies to their specific situation?

Assessment Questions:

Does the patient believe they have the medical condition described?
Do they recognize the need for treatment?
Are they aware of how the condition/treatment affects them personally?
Do they acknowledge the potential consequences for their specific situation?

Clinical Observations and Notes

Appreciation Assessment

Met Patient appreciates their situation Not Met Patient does not appreciate their situation Unclear Further assessment needed

3. Reasoning

Can the patient logically evaluate information to make a rational decision?

Assessment Questions:

Can the patient weigh the risks and benefits of different options?
Do they provide logical reasons for their treatment preference?
Can they explain the consequences of their decision?
Is their reasoning process coherent and goal-oriented?

Clinical Observations and Notes

Reasoning Assessment

Met Patient demonstrates logical reasoning Not Met Patient's reasoning is impaired Unclear Further assessment needed

4. Expressing Choice

Can the patient clearly and consistently communicate their decision?

Assessment Questions:

Can the patient clearly state their treatment choice?
Is their choice consistent over time?
Can they communicate their decision without ambiguity?
Do they maintain their choice when asked to reconsider?

Clinical Observations and Notes

Choice Expression Assessment

Met Patient can clearly express choice Not Met Patient cannot clearly express choice Unclear Further assessment needed

Additional Clinical Considerations

Risk Level of Decision

Factors That May Affect Capacity

Additional Clinical Notes

Assessment Summary

Legal Disclaimer: This tool is designed to assist clinicians in systematically evaluating decision-making capacity. It is not a substitute for clinical judgment and does not constitute legal advice. The assessment of capacity should always consider the specific context, patient condition, and applicable laws. Clinicians remain responsible for all medical decisions and documentation.