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June 1, 2025

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

Hosts:
Anne Levine, MD
Brian Gilberti, MD

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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:
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