Episode 210: Capacity Assessment

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

Hosts:
Anne Levine, MD
Brian Gilberti, MD

June 1st, 2025 Download Leave a Comment

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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