We discuss capacity assessment, patient autonomy, safety, and documentation.
Hosts:
Anne Levine, MD
Brian Gilberti, MD



https://media.blubrry.com/coreem/content.blubrry.com/coreem/Capacity_Assessment.mp3



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Show Notes
The Importance of Capacity Assessment

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



Defining Capacity

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



Real-World ED Examples

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



The 4 Pillars of Capacity Assessment

Understanding

Can the patient explain:
Their condition
Recommended treatments
Risks and benefits
Alternatives and outcomes?


Sample prompts:

“What are the options for your situation?”
“What might happen if we do nothing?”


Appreciation

Does the patient grasp the personal relevance of the information?
Sample prompts:

“Why do you think we’re recommending this?”
“How do you think this condition could affect you?”




Reasoning

Can the patient logically explain their choice?
Must demonstrate a rational process, even if the outcome seems unwise
Sample prompts:

“What factors are you considering in making this decision?”
“What led you to this conclusion?”




Choice

Is the patient able to clearly communicate a decision?
Any modality acceptable: verbal, written, gestural
Sample prompts:

“We’ve discussed several options. What do you want to do?”
“Have you decided what option is best for you?”





Common ED Challenges & Solutions
Time Pressure

Capacity assessments can be time-consuming
Yet, patients leaving AMA without proper evaluation are at higher risk:

↑ 30-day mortality
↑ 30-day readmission



Communication Barriers

Language differences → use certified interpreters
Cognitive impairment or psych illness → clarify baseline status
Noisy ED environment → relocate to quiet space
Use simple language, avoid jargon

Ethical Dilemmas

Providers may disagree with patient choices
Ensure decision-making process—not the choice itself—is being judged
Use tools like the Aid to Capacity Evaluation (ACE)
When uncertain, consult Psychiatry or Risk Management

Best Practices in Documentation
Clearly document:

The patient’s understanding, appreciation, reasoning, and choice
Information delivered:

Condition
Treatment recommendations
Alternatives and risks


Patient’s responses and logic
Witnesses to the conversation
Any discharge instructions, including:

Follow-up plans
Prescriptions provided
Return precautions



Also document:

If patient refused treatment, document:

That risks and benefits were clearly explained
That refusal was voluntary


If treatment was administered despite objection:

Document rationale for presumed lack of capacity
Legal/ethical justification for action
Involvement of other services (e.g., Psychiatry, Risk)

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