To decide or not to decide, that is the dilemma: Real-time tool for assessing decision making capacity at the bedside

Abstract: Decision making capacity allows a person to make a purposeful decision about a choice. Assessing patients for decision-making capacity (DMC) remains a challenging yet essential ethical skill for clinical care. If a patient has DMC, they can provide consent or refusal to an intervention. If a patient lacks DMC, clinicians turn to a surrogate to make decisions on their behalf to interpret the patient’s known wishes and values. We know that surrogate decision making has inherent limitations, and whenever possible we prioritize diligent capacity assessment to elicit patient wishes as the most accurate way to respect patient autonomy.
The nuance in the assessment of DMC persists because it is a functional assessment. Its fluctuating nature means each situation requires an independent assessment. Busy clinicians need a thorough, thoughtful, and organized approach to assess DMC. We offer such a comprehensive framework in the form of a mnemonic that clinicians can remember at the bedside to assess and document capacity.
We review WELSCoRED: What is the medical decision, Expressing a choice, Level of risk of the decision, Situational understanding, Consequence appreciation, Rationale for the choice, Evaluate for capacity, Date/Time. The proposed tool is compared with validated criteria and is found to include all key elements of capacity assessment.
We believe use of such a tool can provide a much-needed systematic approach for assessing DMC in complex circumstances, thereby preserving patient autonomy and safety.

Keywords: Decision Making Capacity, Capacity Assessment, Capacity documentation