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,
