Documentation of Decision-Making Capacity, Informed Consent, and Health Care Proxies: A Study of Surrogate Consent

Abstract

Patients in the general hospital are routinely asked to make decisions about their medical care. However, some of them are unable to express a choice, understand the information provided, weigh the options, or make a decision for themselves; when this occurs, the task of making an appropriate medical decision is left to another-a substitute decision-maker (SDM). We sought to understand the practice patterns surrounding surrogate consent. We hypothesized that SDMs would be used frequently for patients with an altered mental status (AMS) but that there would be insufficient documentation of health care proxies (HCP) and of clinician assessment of a patient's decision-making capacity. A retrospective chart review was conducted on inpatients who underwent a lumbar puncture. The review assessed whether patients had a HCP in the record, if the patient's mental status was evaluated prior to obtaining informed consent, if the patient's capacity was addressed in this assessment, and whether a SDM was asked to provide the informed consent. Consistent with our hypotheses, we found that the majority of patients did not have documentation of a HCP in the record. We found that the mental status of all patients was assessed prior to the procedure, but that documentation regarding assessment of decision-making capacity was lacking. Our pilot investigation suggests that there is need for improvement in our evaluation and documentation of altered mental status and a patient's ability to make informed decisions. To this end, several quality-improvement suggestions are discussed.