How do you decide when to formally re-assess and document decisional capacity in a hospitalized patient who initially lacks it?

This is a great question and tricky to answer in every scenario. In general, we should be reassessing decisional capacity with each clinical encounter, though formal documentation may not be necessary each time. My approach is based on considering several factors:

1. What is the underlying cause of the patient's lack of decisional capacity? Electrolyte imbalances, delirium, and medication or recreational drug effects may all resolve fairly quickly. Dementia and other more chronic conditions may no...

Decisional capacity is always task-specific, so the first step is to identify the exact decision. Capacity for what? The threshold to accept a low-risk, high-benefit intervention like a CBC or a non-contrast CT is low, while the threshold to refuse that same intervention is higher. People are allowed to make bad decisions we do not agree with, which is why the capacity question has to stay tightly focused on the specific task.

Once the specific decision is identified, reassessment tends to happe...