CCRN · Professional Caring and Ethical Practice · 7 min read
Capacity, Informed Consent and Surrogates
- Differentiate clinical decision-making capacity from legal competence and identify reversible physiological contributors to fluctuating capacity in the critical care setting.
- Define the professional and legal boundaries of the critical care registered nurse's role in informed consent, informed refusal, and emergency implied consent under the AACN Synergy Model.
- Apply ethical standards of surrogate decision-making, advance directives, portable medical orders, and code status specifications to advocate for patient autonomy during clinical decision-making and ethical conflict.
Decision-Making Capacity Versus Legal Competence
In critical care nursing practice, distinguishing between decision-making capacity and legal competence is essential for protecting patient rights. Decision-making capacity is a clinical assessment performed by healthcare clinicians for a specific decision at a specific time. Because critical illness evolves rapidly, capacity is decision-specific and can fluctuate throughout a critical care admission. Conversely, legal competence is a formal determination made exclusively by a judge in a court of law. A patient who is legally competent may temporarily lack decision-making capacity due to acute illness, sedation, or delirium. Similarly, a patient with chronic psychiatric illness or dementia may still possess capacity to make specific, discrete medical decisions regarding their care.
When a patient's capacity appears impaired, the critical care nurse must assess for potentially reversible contributors and communicate these concerns to the healthcare provider. Common reversible factors in the intensive care unit include sedative effects, hypoxemia, sepsis, and metabolic disturbances. Nurses use validated tools such as the Confusion Assessment Method for the ICU to screen for delirium, a potential contributor to impaired capacity; a delirium screen does not determine decision-making capacity.
Clinical protocols often guide the reduction of psychoactive infusions. When clinically safe and permitted by orders or protocol, reducing sedation may help assess cognition. However, achieving a specific target on a sedation scale does not guarantee intact cognition; a Richmond Agitation-Sedation Scale score of 0 to −1 alone does not establish capacity. Furthermore, when clinically appropriate under orders or protocol, spontaneous awakening trials offer opportunities to reassess alertness and screen for delirium. Nevertheless, neither spontaneous awakening trials nor spontaneous breathing trials establish decision-making capacity, as capacity requires higher-order cognitive processing beyond basic neurological responsiveness.
Common mistakes
- Assuming that signing as a witness on an informed consent form makes the critical care nurse legally responsible for explaining procedural risks, benefits, and alternatives.
- Believing that an active Do Not Resuscitate order requires withholding all critical care interventions, such as blood products, antibiotics, or vasopressor titrations, prior to cardiac or respiratory arrest.
- Assuming that legal competence and clinical decision-making capacity are synonymous, or that passing a spontaneous awakening trial or spontaneous breathing trial confirms capacity.
- Permitting emergency implied consent to proceed for a treatment when there is a known, valid, and applicable prior refusal by the patient.
Key points
- Decision-making capacity is a clinical, decision-specific assessment conducted by clinicians that fluctuates with acute illness, whereas legal competence is determined solely by a judge.
- To possess capacity, a patient must understand the condition and options, appreciate personal relevance, reason logically using personal values, and communicate a choice.
- The healthcare provider holds the legal responsibility for explaining procedural risks, benefits, and alternatives; the nurse witnesses the signature, assesses for barriers, pauses the process if questions remain, and advocates under the AACN Synergy Model.
- An adult with capacity maintains the autonomous right of informed refusal, even if declining treatment leads to death; disagreement with medical advice does not prove incapacity.
- A living will records treatment preferences, a healthcare power of attorney designates an agent whose authority follows the document and applicable law, and POLST/MOLST forms provide portable medical orders; a patient who regains capacity resumes making their own healthcare decisions.
- Surrogates should use substituted judgment when the patient's known wishes and values sufficiently guide the decision; when they do not, the best interests standard applies, consistent with applicable law.
Practice this section
Explained CCRN Professional Caring and Ethical Practice questions, no account needed. CCRN Professional Caring and Ethical Practice practice test
The full lesson continues with 4 more sections with exam tips, audio in English and Spanish, 5 Check yourself questions and 20 flashcards.
- 1 month
$58.99$29.49 - 3 months
$173.99$86.99 - Lifetime
$350.99$175.49
One payment, no subscription.
See CCRN plansAlready a member? Log in
Sample lesson: The AACN Synergy Model25 practice questions on this exam
Each CCRN practice test has 25 original questions with the answers explained. No account needed.
Open the CCRN practice testsOriginal lesson written for CCRN practice · updated October 31, 2026. Exam names are trademarks of their owners; tests.global is not affiliated with them.