Decision-making guidelines have been suggested for patients
with delirium who lack decisional capacity or competence to give
informed consent (129). The urgency with which treatment is needed and
the risks and benefits of treatments can be used by the treating
physician to choose between several alternative courses of action.
In medical emergencies requiring prompt intervention, the first alternative
is to treat the patient with delirium without informed consent,
under the common-law doctrine of implied consent (i.e., that treatment
may be provided in medical emergencies without informed consent
if it is appropriate treatment that a reasonable person would want).
In nonemergency situations, the clinician should obtain input or
consent from surrogates. Involving interested family members can
be especially helpful for choosing among equally beneficial interventions
that involve low or moderate risks. The opinion of a second clinician
can be useful for making decisions involving more uncertainty or
interventions associated with greater risks. Obtaining the consultation
of a hospital's administrator, risk manager, or legal counsel
may also provide a means for reassuring family members and the treatment
team that reasonable decisions are being made. For decisions that involve
significant risks or substantial disagreements involving family
members, a court-appointed guardian can be sought if time permits.
In more emergent cases, an urgent hearing with a judge may be required.
All assessments of a patient's decisional capacity or competence
and the reasons for a particular course of action should be documented
in the patient's medical record.