Focus on the decision being considered
Decision-making capacity concerns a person’s ability to participate meaningfully in a health care decision. The Veterans Health Administration’s consent directive describes understanding and appreciating the nature and consequences, forming a reasoned judgment and communicating a clear decision. This is a VA framework; authority to make a formal determination depends on the applicable setting and rules.
Nursing observations can help the responsible team understand what the patient can explain, what remains unclear and what communication support is needed. Avoid substituting a label such as “difficult” for a description of the actual conversation.
Make observations specific
Identify the decision under discussion and the information provided. What did the patient say they understood? Could they describe how the options related to their own situation? What reasons did they give? How did they communicate the choice?
These questions help organize observations; they are not a stand-alone capacity test. A cognitive screening result, agreement with the recommended plan or ability to state a name and date should not be treated as the entire consent conversation.
Ask the responsible clinician how concerns should be assessed and documented. Do not conclude that disagreement itself establishes incapacity. Instead, describe the concern that needs evaluation and the information that led to it.
Support communication before drawing conclusions
In a fictional encounter, a patient gives inconsistent answers while unable to hear the explanation clearly. The immediate communication task is to arrange the appropriate support and reassess understanding through the care team, rather than assume that the responses settle the question.
AHRQ’s teach-back approach asks patients to explain information in their own words and uses their responses to improve the explanation. That can reveal a communication gap. It cannot independently determine whether a person has legal or clinical authority to make a particular decision.
Consider whether the conversation was rushed, whether the patient had a chance to ask questions and whether the communication method matched their needs. Record relevant conditions so the evaluator can interpret the observations.
Keep the patient involved
The AMA’s ethics guidance advises involving patients to the extent their capacity allows, even when a surrogate is participating. A surrogate’s presence should not make the patient disappear from the conversation.
For handoff, communicate the specific concern, who was asked to evaluate it and what remains unresolved. Avoid carrying a broad incapacity label forward without explaining its source and relevance. Use the organization’s process when circumstances or decisions change.
For the related consent workflow, see the nurse’s role in informed consent. When the team determines that another decision maker is needed, follow the applicable surrogate process, rather than assuming the most available relative automatically has authority.
Sources
- VHA Directive 1004.01(3): Informed Consent for Clinical Treatments and Procedures (accessed 2026-09-17).
- AHRQ: Use the Teach-Back Method (accessed 2026-09-17).
- AMA Code of Medical Ethics: Decisions for Adult Patients Who Lack Capacity (accessed 2026-09-17).