FACILITY
SAMPLE POLICY AND PROCEDURE
SECTION: FACILITY
SUBJECT: DECISION MAKING CAPACITY
/INFORMED CONSENT
POLICY/PROCEDURE #: ____
FORM’S REFERENCE #:
CONTACT AND CAPACITY
FORM (C and C)
REFERENCE/AUTHORITY: Patient Self-Determination POLICY REFERENCE #:
Act
POLICY:
1. This facility supports the rights of a resident to make his/her own health care decisions, when
possible.
2. It is assumed that residents have the capacity to provide informed consent, unless this has legally
or clinically been determined otherwise, but this is re-evaluated in each situation by the physician
or other licensed health care provider.
DEFINITION:
Capacity means a person’s ability to understand the nature and consequences of proposed health care,
including its significant benefits, risks and alternatives, and to make and communicate a health care
decision. All persons are presumed to have the capacity to make a health care decision, to give or
revoke Advanced Health Care Directives and to designate or disqualify a surrogate, unless determined
otherwise.
PROCEDURE:
1. Physician shall determine resident’s capacity to provide informed consent upon admission to the
facility and at each time when informed consent is required (e.g. administration of psychotropic
medication, procedure or discharge) and document this assessment in medical record. In this
determination, physician may consult with resident, his/her family and friends and other healthcare
team members.
2. Residents with capacity to provide informed consent are to be informed of risks and benefits of
treatments and therapies or no treatment, and can sign all appropriate consents. When a resident
lacks the capacity to provide informed consent, a surrogate decision-maker shall be informed of
risks and benefits of therapies or treatments and sign informed consent documentation.
3. For consent issues related to admission, surgery, discharge or psychotropic medications,
physicians must be involved in the assessment. Other trained staff may assess for capacity to make
other individual decisions that are required (e.g. capacity to make the decision to leave the facility
unaccompanied, to accept or refuse a certain treatment option, to establish preferred intensity of
care).
4. In general, residents on Public Guardian Conservatorship lack the capacity to provide informed
consent, although they may be able to express their needs and wishes. Residents on Lanterman
Petris Short (LPS) Conservatorship may or may not maintain the right to provide informed consent
for medical procedures.
5. Resident’s capacity to make health care decisions is reflected on the Facesheet and Consent and
Capacity sheet as follows:
a. Residents may be identified as having full capacity to make “all” decisions, in which
case, the decision maker is identified as self. The resident is asked who might be a
surrogate in the event they are unable and encouraged to complete an advance directive.
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FACILITY
SAMPLE POLICY AND PROCEDURE
The resident may elect to choose another individual to be notified or to assist indecisionmaking. The resident’s wishes are reflected on the Facesheet and in the Care Plan.
b. Residents may be identified as no or marginal capacity either due to profound cognitive
impairment or severe communication difficulties or psychiatric conditions. Some of these
residents may have a conserveratorship established which removes certain decisionmaking rights, while others are determined through clinical observation and assessment.
Occasionally, these individuals may be able to state an individual to assist in decision
making, but this capacity must be reviewed by a clinician. In the event that a resident is
determined to be unable to provide informed consent, or otherwise lack decision-making
capacity for a particular medical intervention or treatment, a surrogate decision-maker
will be appointed. Their Facesheet, C and C form, and Care Plan will reflect their lack of
capacity; they will have a representative payee, and a decision-maker.
c. In many cases, there is limited capacity to make decisions which must be individually
assessed based on the decision to be made. For example, they may have the capacity to
sign in (agree to treatment), but not to give informed consent for psychotropic
medications. The C and C form will state “limited” and will outline the decisions the
resident can make.
6. Resident’s capacity to make health care decisions shall be reviewed with any significant change of
condition and at quarterly care conferences. Changes will be submitted to the Business Office by
the social worker or designee to be reflected on the face sheet. The Social Worker will update the
Consent and Capacity form and place a copy in the chart, to be stored behind the Facesheet.
7. Residents may refuse a treatment for religious or other personal reasons. Such refusal does not
generally show that resident lacks decision-making capacity. If a resident understands proposed
treatment or procedure and can communicate his/her decision, such decision will be respected by
Interdisciplinary Team (IDT), even if it appears to be unwise.
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