Core EM - Emergency Medicine Podcast

Episode 210: Capacity Assessment

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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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