4.2 Decisional Capacity and Decision Makers

Blueprint Focus: Who Decides?

Topic 1B6 asks hospital case managers to assess decisional capacity and identify the appropriate decision maker. Transition planning collapses when the team teaches and obtains consent from the wrong person—or when no one has clear authority and discharge stalls.

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Capacity Versus Competence

Decisional capacity is a clinical determination that a person can make a specific healthcare decision at a specific time. Competence (or incompetency) is a legal status determined by a court. A patient may lack capacity for a complex surgical consent today because of delirium yet retain capacity tomorrow after treatment—or retain capacity to choose a discharge destination while lacking capacity for research enrollment.

Key principles:

• Capacity is decision-specific — agreeing to a blood draw is not the same as consenting to high-risk surgery or declining life-sustaining treatment
• Capacity is time-specific — reassess when mentation changes
• Capacity is not the same as agreeing with the medical team — patients with capacity may refuse recommended care
• Cognitive impairment, dementia, psychiatric illness, intoxication, or language barriers raise the need for careful assessment; none automatically equal incapacity

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Elements of a Capacity Assessment

Clinicians commonly structure assessment around four functional abilities (often associated with Appelbaum’s framework):

1. Understand — Can the patient explain the condition, the proposed options, and the main risks/benefits in their own words?
2. Appreciate — Does the patient grasp that the information applies to them (not only abstractly)?
3. Reason — Can the patient compare options and describe how they reached a preference?
4. Express a choice — Can the patient communicate a consistent decision?

Case managers do not replace the attending or licensed independent practitioner responsible for consent, but ACM practice requires recognizing red flags (waxing/waning alertness, inability to paraphrase the plan, choices that flip without new information) and escalating promptly. Document observations that support the clinician’s capacity determination. Use qualified interpreters for language barriers—never assume limited English proficiency equals lack of capacity.

Practical bedside approach

• Ask the patient to teach-back the diagnosis and options
• Explore values: “What matters most to you about going home versus rehab?”
• Check consistency across shifts and after optimizing reversible causes (pain, hypoxia, metabolic derangement, sleep, medications)
• Distinguish unwise decisions from incapable decisions

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When the Patient Has Capacity

If the adult patient has capacity, the patient is the decision maker. Family preference does not override a capacitated adult’s choice. Case management roles include:

• Ensuring informed discussion of disposition options with the patient
• Clarifying to family that the patient directs care unless they authorize otherwise
• Documenting the patient’s goals and choices in the plan of care
• Offering—but not forcing—family involvement preferred by the patient

HIPAA and facility policy still govern what may be shared with family; capacity to decide about treatment is related to, but not identical with, authority to access the full record.

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When Capacity Is Lacking: Finding the Decision Maker

If the patient lacks capacity for the decision at hand, identify the legally authorized decision maker under state law and facility policy. Typical priority order (exact order is state-specific):

1. Healthcare agent / proxy named in a durable power of attorney for healthcare (POAHC) or equivalent advance directive
2. Court-appointed guardian (or conservator) with healthcare authority
3. Default surrogate under state statute — often spouse/domestic partner, then adult children, parents, siblings, then other relatives or close friends, depending on jurisdiction
4. Institutional pathways when no surrogate is available — ethics committee, risk management, public guardian petition, or other state mechanisms

Surrogate standards

Authorized decision makers should use substituted judgment (what the patient would have wanted) when patient values are known, and a best-interest standard when values are unknown. Case managers help by gathering prior statements, advance directives, and collateral history from trusted contacts.

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Common Conflict Patterns and CM Response

Family disputes — Adult children disagree about SNF versus home. Confirm whether an agent is named; if not, apply state hierarchy and facilitate a structured family meeting with the attending. Do not let the loudest relative become the de facto decision maker.

Document present but ignored — A POAHC exists in the EHR, yet staff keep asking the spouse who is not the agent. Retrieve the document, educate the team, and route decisions to the named agent when the patient lacks capacity.

Fluctuating capacity — A patient with hepatic encephalopathy clears after treatment and wants to revoke a prior refusal. Reassess capacity and honor a capacitated patient’s updated choice.

No identifiable surrogate — Early escalation prevents day-of-discharge gridlock. Involve social work, risk, ethics, and, when required, legal/public guardian processes while medical care continues under emergency exceptions as applicable.

Psychiatric holds and capacity — Involuntary psychiatric status addresses danger to self/others or grave disability under state mental health law; it does not automatically answer every medical consent question. Clarify which decisions the patient may still make and who holds authority for others.

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Documentation and Communication Expectations

Strong ACM documentation for 1B6 includes:

• Whether capacity was assessed for the relevant decision and by whom
• The basis for concern (examples of failed teach-back, inconsistency)
• Identity and contact information of the authorized decision maker and the source of authority (document type, guardianship papers, statutory relationship)
• Efforts to locate directives or next of kin
• Ethics/risk involvement when authority is contested

Communicate findings to the interdisciplinary team so utilization, consent, and disposition conversations target the correct person. Misdirected teaching wastes hours and creates legal exposure.

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Exam Anchors

• Capacitated adults decide for themselves
• Capacity ≠ agreement with clinicians; capacity ≠ global label for the entire stay
• Prefer the named healthcare agent over informal family preference when the patient lacks capacity
• Know that state law sets default surrogate order and formalities—ACM items test the logic of hierarchy and process, not every state’s statute line-by-line
• Escalate early when capacity or authority is unclear rather than delaying safe transition planning