Capacity
A physician's, psychiatrist's or psychologist's opinion on an individual's ability to manage own personal, medical and/or financial matters.
What is capacity?
Who can file for guardianship?
Anyone over 18. Note: Inspira can provide guidance to patients, families and community entities, but they too can file independently. Note there are special circumstances in which you want to review with leadership.
True or False: Discharge planning stops when guardianship is pending
FALSE: Care coordination should continue to progress a discharge plan while guardianship is pending. This is case by case so you'll need to use your judgement.
Explain the difference between an emergent vs. urgent procedure as it relates to special medical guardianship request.
Emergent means there's a lifesaving intervention immediately needed that is life saving and cannot wait until a special medical guardian or decision maker to be established (i.e. coding in the ED)
Urgent is medically necessary and would cause harm to patient if not addressed within a few days.
True or False? Patient lacks capacity, there is no AD/POA/POLST/NOK and needs an urgent procedure, two physicians can provide consent.
FALSE. Only in emergent life saving situations can physicians proceed with life saving measures in the absence of an AD/POA/POLST/NOK.
A judge's ruling on an individual's ability to manage own personal, medical and/or financial matters.
What is competency?
True or False: Only a relative can file for guardianship.
False. We've had a case in which a neighbor/good friend to the patient initiated a guardianship application in the community prior to hospital admission.
How long are physician certifications good for?
30 days
Where do original physician certifications go?
Your supervisor. Copies remain on chart and are to be uploaded in EPIC. You will also scan and email to your supervisor with the guardianship SBAR. Note: Salem Co requires the original certifications. This can be tricky since Array Psychiatry is a remote service. Suggest hospitalists to complete both sets.
Who can complete physician certification forms for capacity?
What are physicians? Forms cannot be completed by APN's, residents or students - however they can prepare the document for their physician to sign. Technically there are forms psychologists can complete for guardianship, but this is not typically Inspira's process.
True or False: NJ Law provides guidance on next of kin in absence of an AD/POLST/POA for medical decision making.
False. This is why it's important to obtain all NOK information and document family feedback. Please referral to Hospital Legal Counsel's Power Point saved in guardianship folder for further details (slide #20).
True or False: Once a guardianship application is initiate we can not refer to PATHS.
False. If there is a point of contact/anticipated guardian, we can still connect with PATHS to explore what documents we are able to obtain to continue to progress the discharge plan. This is case by case and you will need to use your judgement.
When is a special medical guardian (SMG) is needed what forms will need to be completed by the physicians?
Generally speaking - it's when a medically urgent procedure is needed and cannot wait months for permanent guardianship to be established. 2 physician certifications are needed, plus the special medical guardianship form completed by 1 of the 2 physicians. If a physician is requesting a SMG please send an SBAR to your supervisor ASAP for review.
It's been established that a patient lacks capacity by the physician, and your supervisor has provided guidance that guardianship is needed. You have requested physician certifications, and they are still pending after 24 hours. Who can you elevate this delay to?
What is the physician advisor? The expectation is that physician certifications are completed within 24 hours of being requested. Please provide a friendly reminder in rounds, but if you are still not making progress, please elevate to your supervisor and/or physician advisor.
True or False: Capacity can only be assessed by a psychiatrist.
False. Any physician can assess for capacity.
True or False: It's not important to document conversations with next of kin.
False. Your documentation is provided to legal to explain why a guardianship is needed and, if Inspira is filing, it provides the why. Your documentation may also help in providing clarity as to who the appropriate guardian should be. Be mindful to document just the facts.
True or False: The Guardians must also become the caregiver for the incapacitated individual?
False. This is a common question and worry of families. Share the guardianship video link in the shared drive to help them better understand the role of a guardian. It is not synonymous with caretaker. They will become the surrogate decision maker if appointed.
True or False. Inspira is filing for guardianship. A family member is interested in serving as the guardian. All they need to do is tell the hospital social worker.
FALSE. They will need to submit forms to the Surrogate Office including a background check, fingerprints and certification that they watched the guardianship training video. This needs to be done timely so it is processed before court. If not, the hearing may be delayed, or they will not be considered.
Where can guardianship documentation and resources be located?
1. Shared Drive: Care Coordination L Drive ->Resources -> Guardianship
2. Policy Tech
True or False: Capacity does not change.
False. Capacity is fluid. We have had cases canceled because they regained capacity which is why it's important to monitor and continue communicated with the 'alleged incapacitated' in case you observe improvement. Also important to ensure patient is medically stable prior to a capacity evaluation (assuming this isn't for a special medical guardian).
There are no contacts listed on patient's record. Where can you search for next of kin contacts?
Multiple answers: Old records, physician offices, community service providers patient was previously connected with, Google search, obituaries, patient's cell phone/wallet (if they allow for it - be gentle).
Can a patient be discharged while guardianship is pending?
Yes. A court order can be requested to follow through on a discharge plan. For example, we often request court orders to provide someone with authority to consent to a skilled nursing facility transfer if there is an accepting facility and physician note reflecting patient is medically stable for hospital discharge to a skilled nursing facility.
Who makes the determination proceed with the guardianship process and initiate physician certification requests?
What is Leadership? SBAR is to be send to your supervisor when a patient lacks capacity and there are no legal documents for a decision maker. Be careful not to jump right to guardianship when a capacity evaluation is requested. There needs to be a pause to review next of kin and then have a conversation via an SBAR with your supervisor.
True or False: An individual can have capacity in some areas and lack capacity in other areas.
True. There are options for limited capacity, although majority of the time we request 'global capacity' to be evaluated.