We discuss capacity assessment, patient autonomy, safety, and documentation.

Hosts:
Anne Levine, MD
Brian Gilberti, MD

• Arises frequently in the ED, even when not formally recognized
• Carries both legal implications and ethical weight
• Failure to appropriately assess capacity can result in:
  • Forced treatment without justification
  • Missed opportunities to respect autonomy
  • Increased risk of litigation and poor patient outcomes

• Capacity is:
  • Decision-specific: varies based on the medical choice at hand
  • Time-specific: can fluctuate due to medical conditions, intoxication, delirium
• Distinct from competency, which is a legal determination
• Relies on a patient’s ability to:
  • Understand relevant information
  • Appreciate the consequences
  • Reason through options
  • Communicate a clear choice

• Intoxicated patient with head trauma refusing CT
  • Unreliable neuro exam
  • Potentially time-sensitive intracranial injury
• Elderly patient with sepsis refusing admission due to caregiving responsibilities
  • Balancing autonomy vs. beneficence
• Patient with gangrenous diabetic foot refusing surgery
  • Demonstrates logic and consistency despite high-risk decision

• Understanding
  • Can the patient explain:
  • Their condition
  • Recommended treatments
  • Risks and benefits
  • Alternatives and outcomes?
• Sample prompts: