Ethics, Communication & Professionalism

Capacity assessment: distinguishing from competence

Clinical Overview and When to Suspect Impaired Capacity

— Physicians assess capacity; courts adjudicate competence.

— A patient declared legally competent may still lack capacity for a given medical decision (e.g., delirium); a patient deemed incapacitous clinically is not automatically incompetent legally.

— Patient refuses recommended life- or limb-saving treatment, OR insists on a clearly harmful intervention.

— Sudden change in mental status, fluctuating attention, or new psychiatric symptoms (delirium, psychosis, mania, severe depression).

— Cognitive impairment: dementia, intellectual disability, traumatic brain injury, stroke.

— Intoxication, withdrawal, or active substance use during the encounter.

— Decisions out of character or inconsistent with stated values.

— Communication barriers that make reasoning hard to evaluate (always rule out language/sensory issues first with interpreter or hearing aids).

— A higher-stakes or higher-risk decision (refusing intubation in respiratory failure) requires a more rigorous demonstration of capacity than a low-risk one (choosing a meal).

— A patient with mild dementia may have capacity to designate a healthcare proxy but not to manage finances or consent to a Whipple.

Board pearl: On Step 3, the stem that says "the patient was declared competent last year by a judge" is a distractor — you still must assess capacity for this decision, today. Capacity is dynamic; competence is a court order.

Capacity = a clinical determination made by any licensed physician at a specific moment in time, for a specific decision, regarding whether a patient can understand, appreciate, reason, and communicate a choice about that decision.

Competence = a legal determination made by a judge that applies globally (or to defined domains) and persists until the court modifies it.

When to suspect impaired capacity (trigger a formal assessment):

Decision-specific and sliding-scale principle:

Presentation Patterns and Key History

— Elderly patient with mild dementia refusing hip fracture surgery.

— Patient with schizophrenia refusing antibiotics for sepsis.

— Intoxicated trauma patient refusing CT scan and signing out AMA.

— Adolescent (often emancipated minor or mature minor doctrine) requesting confidential contraception or STI treatment.

— Severely depressed patient refusing dialysis or chemotherapy "because I deserve to die."

— Jehovah's Witness adult refusing transfusion — capacity is usually intact; the refusal is a values-based choice, not impaired reasoning.

— Baseline cognition: prior MMSE/MoCA, dementia diagnosis, education level, primary language.

— Acute precipitants: infection, hypoxia, electrolytes, medications (benzodiazepines, opioids, anticholinergics, steroids), substances.

— Psychiatric history: psychosis, mood disorder, suicidality, prior involuntary holds.

— Social history: who is the surrogate? Does an advance directive or POLST exist? Healthcare proxy on file?

— Values history: what has the patient previously said about resuscitation, life support, organ donation?

— Always document attempts to reach surrogate when capacity is uncertain.

Step 3 management: Before labeling a refusal as "incapacitous," correct the reversible: treat pain, hypoxia, hypoglycemia; discontinue offending meds; allow intoxication to clear; provide interpreter, hearing aids, glasses. Reassess in hours, not minutes. A capacity assessment performed on a delirious or intoxicated patient and used to override their refusal is both clinically and legally fragile — courts and ethics committees expect you to wait for the reversible cause to clear unless the situation is emergent.

Classic Step 3 vignettes that demand a capacity assessment:

History elements that matter:

Collateral information is essential — family, PCP, prior notes, prior advance directives.

The Four-Component Capacity Exam (Appelbaum & Grisso)

— 1. Understanding — Can the patient restate, in their own words, the diagnosis, the proposed intervention, the alternatives, and the risks/benefits/expected outcomes?

· Ask: "Tell me in your own words what I just explained."

— 2. Appreciation — Does the patient apply that information to their own situation, acknowledging it is real and pertains to them?

· A patient who understands "pneumonia kills people" but says "but I don't have pneumonia, I'm fine" fails appreciation — often a sign of psychosis, denial, or anosognosia.

— 3. Reasoning — Can the patient manipulate the information rationally, weigh risks and benefits, and explain how they reached their decision in a logically consistent manner?

· Delusional reasoning ("the surgeon is poisoning me") fails this prong even if the conclusion (refusing surgery) is articulated.

— 4. Choice (Expressing a Choice) — Can the patient communicate a stable, consistent decision? Repeated reversal or inability to commit fails this prong.

— It is not agreement with the physician — disagreeing with the recommended plan does not equal incapacity.

— It is not the diagnosis — schizophrenia, dementia, or depression alone do not equal incapacity.

— It is not IQ — low cognitive ability with adequate decision-specific understanding can suffice.

Key distinction: Understanding = "What did the doctor say?" Appreciation = "How does it apply to me?" The classic failure point in psychosis and severe dementia is appreciation, not understanding.

Capacity assessment is a structured bedside interview, not a score. The four components (Appelbaum criteria) are the board-tested framework:

Sliding scale: as risk of the decision rises, the threshold for each prong rises. Refusing a flu shot ≠ refusing intubation.

What capacity is NOT:

Tools and Documentation of the Capacity Assessment

— MacCAT-T (MacArthur Competence Assessment Tool for Treatment) — gold-standard structured interview operationalizing the four Appelbaum domains; 15–20 minutes.

— Aid to Capacity Evaluation (ACE) — University of Toronto, free, briefer, decision-specific.

— MMSE/MoCA — screen for global cognition only; a normal MMSE does not confirm capacity, and a low MMSE does not refute it. MMSE <20 raises suspicion; <16 strongly suggests impairment for complex decisions.

— Any licensed physician can perform and document a capacity assessment — psychiatry consult is not legally required in most US jurisdictions.

— Psychiatry consultation is appropriate when: assessment is unclear, psychiatric illness drives the question, family disputes the determination, or the decision is high-stakes and irreversible.

— The specific decision being assessed (e.g., "capacity to refuse coronary angiography today").

— Findings for each of the four Appelbaum prongs with direct patient quotes.

— Reversible factors considered and excluded (delirium screen, medications, intoxication, language).

— Conclusion: capacity present or absent for this decision.

— Plan: if absent, identify surrogate per state hierarchy; if present, document informed refusal.

CCS pearl: On a CCS case where a patient refuses a critical intervention, your orders should be: "Bedside capacity assessment," "Psychiatry consult" (if uncertain), "Social work consult" (to identify surrogate), and "Ethics consult" (if conflict persists). Document, document, document.

Bedside tools (supportive, not diagnostic by themselves):

Who performs the assessment?

Documentation must include:

Two-physician documentation is required in some institutional policies for irreversible high-stakes decisions (e.g., DNR, withdrawal of life-sustaining therapy).

Surrogate Decision-Making When Capacity Is Absent

— 1. Expressed wishes / advance directive — written living will, POLST/MOLST, prior recorded statements. Honor these first.

— 2. Substituted judgment — surrogate decides what the patient would have wanted based on prior values, conversations, and known preferences. Not what the surrogate wants.

— 3. Best interests — used when patient's prior wishes are unknown (e.g., lifelong intellectual disability, infant, never-capacitated adult). Weighs benefits and burdens objectively.

— Court-appointed guardian → durable power of attorney for healthcare (healthcare proxy) → spouse/domestic partner → adult children (majority) → parents → adult siblings → other relatives → close friend → attending physician with ethics committee.

— Family disagreement → ethics consult, sometimes court.

— Surrogate appears to act against patient's prior wishes or best interests → physician may challenge surrogate; ethics consult; rarely court.

Board pearl: A healthcare proxy (DPOA-HC) outranks even a spouse if properly designated — the patient's chosen surrogate trumps the default hierarchy. If the stem mentions a previously executed DPOA-HC document, that person speaks for the patient, period.

Once capacity is determined absent, decision-making shifts to a surrogate using a defined hierarchy of standards.

Standards of surrogate decision-making (in order of preference):

Surrogate hierarchy (varies by state, but typical default order):

Conflicts:

Emancipated/mature minors: Can consent to their own care for reproductive health, STI, substance use, and mental health in most states without parental notification. Pregnancy itself emancipates in many states.

Emergencies, Implied Consent, and the Emergency Exception

— In a true emergency (immediate threat to life or limb), when the patient lacks capacity AND no surrogate is immediately available, physicians may proceed with standard-of-care emergency treatment under the doctrine of implied consent — what a reasonable person would consent to.

— Document the emergency, the lack of capacity, and the unavailability of surrogate.

— Does not override a known valid advance directive refusing the treatment (e.g., a Jehovah's Witness with a clear written refusal of blood, even unconscious and exsanguinating).

— Does not apply to non-emergent decisions — wait for surrogate or capacity recovery.

— Once stabilized, revert to standard capacity/surrogate process.

— Capacitous patient → may sign out AMA after documented informed refusal; you may not physically detain them.

— Incapacitous patient who is a danger to self/others or unable to care for self → may be held under medical hold or psychiatric emergency hold (e.g., 5150 in CA, equivalent statutes elsewhere); use least restrictive means; reassess frequently.

Step 3 management: A delirious post-op patient pulling at the central line and trying to leave the ICU lacks capacity. Order: rule out hypoxia/hypoglycemia/pain, treat reversible causes, use verbal de-escalation first, then family at bedside, then low-dose haloperidol or dexmedetomidine, with physical restraints as last resort and with a time-limited order plus q2h reassessment.

Emergency exception to informed consent:

Limits of the emergency exception:

Holding a patient who wants to leave AMA:

Restraints (chemical or physical) require: clear indication, order with time limit, monitoring per institutional protocol, and documentation of failed less-restrictive alternatives.

Special Scenario — Psychiatric Illness and Capacity

— Active psychosis: delusions directly involving the medical decision (e.g., "the medication is poison") impair appreciation/reasoning.

— Severe depression with cognitive distortion: hopelessness or nihilistic delusions ("I don't deserve treatment") may impair appreciation; treat the depression and reassess.

— Mania: impulsivity, grandiosity, impaired judgment about risk.

— Severe anxiety/panic during the encounter: may transiently impair reasoning; defer if possible.

— Acute suicidality with plan/intent → involuntary psychiatric hold (state statute) for evaluation; this is a safety-based detention, not a global capacity determination, but functionally overrides the patient's refusal of admission.

— Capacity to refuse medical treatment in the same patient must still be assessed separately for each medical decision.

— Often retains "understanding" but fails "appreciation" (distorted body image as part of the illness). Courts have generally upheld involuntary treatment when life-threatening.

— Active intoxication → no capacity; defer non-emergent decisions.

— Sober patient with SUD → presume capacity; SUD diagnosis alone does not impair.

Key distinction: Involuntary psychiatric hold (for danger to self/others/grave disability) is a separate legal mechanism from incapacity to consent to medical care. A patient can be psychiatrically held AND retain capacity to refuse, say, a cholecystectomy. Don't conflate these on the boards.

Psychiatric diagnosis ≠ incapacity. Patients with schizophrenia, bipolar disorder, or major depression frequently retain capacity for many decisions.

Capacity-impairing psychiatric features:

Suicidal patient refusing psychiatric admission:

Anorexia nervosa refusing nutrition:

Substance use disorder:

Special Scenario — Dementia and Cognitive Impairment

— Early/mild dementia: usually retains capacity for many medical decisions, designation of healthcare proxy, simple finances.

— Moderate dementia: loses capacity for complex medical decisions, financial management, often driving.

— Severe/advanced dementia: lacks capacity for nearly all decisions; surrogate decision-making applies.

— Capacity to designate a healthcare proxy — requires only understanding of what a proxy does and a stable choice; threshold is low. Patients with mild-to-moderate dementia often retain this.

— Capacity to consent to research — generally higher threshold; many institutions require independent assessment.

— Capacity to drive, manage finances, live independently — overlap with but distinct from medical decisional capacity; often assessed by OT, neuropsych, social work.

— Testamentary capacity (to make/change a will) — legal standard, narrower than medical capacity; ability to know one's assets, heirs, and nature of a will.

— Assess in the morning, in a quiet room, with family present, with sensory aids; capacity may be present at 9 AM and absent at 9 PM. Document the time and conditions.

— Early disclosure of diagnosis + early advance care planning (proxy, POLST, code status) while capacity intact.

— Reassess capacity at major decision points and as disease progresses.

Board pearl: A patient with moderate Alzheimer dementia and MMSE of 18 can often still validly designate a healthcare proxy — the threshold for this single decision is low (understand what a proxy does, name a stable choice). Don't reflexively say "no capacity" because of the MMSE score.

Dementia is a progressive condition; capacity declines unevenly across domains.

Domain-specific assessments commonly tested:

Sundowning and fluctuating capacity:

Practical Step 3 approach for the dementia patient:

Special Populations — Elderly, Renal/Hepatic Impairment, and Iatrogenic Factors

— Up to 25–40% of older inpatients have impaired capacity at some point, often unrecognized.

— Delirium prevalence on general wards ~15–25%, ICU >50%. Always screen with CAM (Confusion Assessment Method) before assessing capacity.

— Sensory deficits (hearing, vision) are massively underrecognized contributors — provide hearing amplifier, glasses, interpreter before declaring incapacity.

— Benzodiazepines, opioids, anticholinergics (diphenhydramine, oxybutynin, TCAs), gabapentinoids, sedating antiemetics, corticosteroids (psychosis), fluoroquinolones (delirium in elderly), H2 blockers in the elderly.

— Deprescribe or hold offending agents and reassess in 24–72 hours.

— Uremia → encephalopathy → impaired capacity; dialysis may restore capacity.

— Hepatic encephalopathy → impaired capacity; lactulose/rifaximin may restore.

— These are reversible — do not lock in a "no capacity" determination during active encephalopathy if a decision can wait.

Step 3 management: When an elderly inpatient becomes "confused" and the team wants to override their refusal of a procedure, your order set is: CAM screen, finger-stick glucose, pulse ox, urinalysis, basic metabolic panel, medication reconciliation with hold on sedatives/anticholinergics, ensure glasses/hearing aids in place, then reassess capacity in 24 hours before invoking a surrogate for any non-emergent decision.

Elderly hospitalized patients:

Iatrogenic capacity impairment — drugs to scrutinize:

Renal/hepatic impairment:

Polypharmacy review is itself a Step 3 management action — Beers Criteria for potentially inappropriate medications in older adults should be referenced.

Special Populations — Pediatrics, Adolescents, and Pregnancy

— Default: parents/legal guardians consent on behalf of the child under best-interests standard.

— Children should be given developmentally appropriate assent (~age 7+); their dissent should be respected when ethically possible for non-essential interventions.

— Recognized in many states; allows adolescents who demonstrate decisional capacity to consent to certain treatments without parental involvement.

— Legal status (marriage, military, court order, financial independence, parenthood in some states); consents as an adult.

— Contraception, pregnancy care, STI testing/treatment, mental health (often), substance use treatment.

— Confidentiality limits: abuse, suicidality, homicidality — mandatory reporting/disclosure.

— Physician obligation: pursue court order to override parental refusal; involve hospital legal/ethics, child protective services. The child's best interests trump parental autonomy when life is threatened.

— A pregnant patient with capacity retains the right to refuse treatment even when it may harm the fetus; courts have generally not allowed forced obstetric interventions on a capacitous pregnant adult.

— Pregnancy itself emancipates a minor in many states for pregnancy-related care.

Key distinction: A 15-year-old with type 1 diabetes whose Christian Scientist parents refuse insulin is a court-order case — life-threatening, curable, parental refusal not in best interests. A 15-year-old refusing a cosmetic procedure her parents want is a mature minor assent case — respect dissent.

Minors (generally <18):

Mature minor doctrine:

Emancipated minor:

Confidential adolescent services (in most US states, without parental consent):

Parental refusal of life-saving treatment for a child (e.g., refusing transfusion, refusing insulin, refusing chemo for curable leukemia):

Pregnancy:

Complications and Adverse Outcomes of Capacity Errors

— Violates patient autonomy; constitutes battery if treatment is forced.

— Bias risks: ageism, ableism, language/cultural bias, equating disagreement with the team for irrationality.

— Legal liability: civil suits for assault/battery, loss of trust.

— Patient signs out AMA, refuses treatment, makes harmful choices; physician/system may be liable for negligence if the assessment was inadequate.

— Patient harm: missed sepsis treatment, suicide, financial exploitation.

— "Signing the AMA form" does not by itself confirm capacity. Document the capacity assessment before the form.

— Insurance myth: there is no truth to the claim that insurance won't pay for an AMA discharge — counsel patients honestly.

— Provide: written discharge instructions, prescriptions if appropriate, return precautions, follow-up plan, offer to return without judgment.

— Aspiration, deconditioning, pressure injury, delirium worsening, deaths from positional asphyxia.

— Splitting between family members; moral distress in staff; ethics committee load.

Board pearl: The most common cause of a capacity-related lawsuit is inadequate documentation — not the determination itself. A note that simply says "patient lacks capacity" without the four Appelbaum prongs, quotes, and decision specificity is legally indefensible. On Step 3, the "best next step" after determining capacity is always document the assessment in detail.

Overcalling incapacity (false positive):

Undercalling incapacity (false negative):

AMA discharge pitfalls:

Restraints and chemical sedation complications:

Family/surrogate conflict:

When to Escalate — Psychiatry, Ethics, Legal, and Court

— Capacity question is complex or contested.

— Psychiatric illness is the suspected cause of impairment.

— Need to initiate involuntary psychiatric hold.

— Suicidality or homicidality is present.

— Family or surrogate disagrees with the team or with each other.

— Surrogate appears to act against patient's known wishes.

— Requests for non-beneficial treatment ("futility" disputes).

— Withdrawal-of-life-support disagreements.

— Conscientious-objection conflicts.

— Court order being considered (parental refusal for child, treatment over objection of incapacitous patient where surrogate unclear).

— AMA discharge of patient with borderline capacity.

— Allegations of abuse, neglect, or exploitation by surrogate.

— Guardianship petitions for chronically incapacitous patients with no available surrogate.

— Override of parental refusal in pediatric life-threatening situations.

— Adjudication of competence (formally a legal, not medical, action).

— Mandatory reporting in most states for suspected abuse/neglect/exploitation of a dependent adult, regardless of patient's capacity to consent to the report.

CCS pearl: On a CCS case where family and team disagree about goals of care for an incapacitous patient, the highest-yield orders are sequential: "Family meeting," "Ethics consult," "Palliative care consult" — before "Court order," which is the option of last resort and rarely correct on the boards.

Psychiatry consultation indicated when:

Ethics committee consultation indicated when:

Risk management / hospital legal indicated when:

Court involvement (rare, slow) for:

Adult Protective Services (APS):

Key Differentials — Conditions That Mimic or Coexist with Incapacity

— Delirium vs. dementia vs. depression ("the 3 D's"):

· Delirium: acute, fluctuating, inattention, reversible cause — capacity often transiently absent, often recoverable.

· Dementia: chronic, progressive, stable course — capacity declines gradually, decision-specific.

· Depression: may cause pseudo-dementia and nihilistic thinking impairing appreciation; capacity often recovers with treatment.

— Aphasia (especially expressive/Broca's): patient may fully understand but cannot express — communication-aided assessment (writing, yes/no, picture boards) is mandatory before declaring incapacity. Receptive (Wernicke's) aphasia is harder; speech therapy assistance helps.

— Catatonia: cannot communicate a choice; treat (lorazepam challenge) before declaring capacity absent permanently.

— Locked-in syndrome: full cognition with no motor output — capacity is intact; use eye-blink communication.

— Religious or cultural values-based refusal (Jehovah's Witness, Christian Scientist) → capacity usually intact.

— Distrust of the medical system (often historically grounded) → capacity intact; address with empathy and rapport.

— Health literacy gap → not incapacity; re-educate using teach-back.

Key distinction: A stroke patient with expressive aphasia who shakes head "no" to surgery is not necessarily incapacitous. Bring in speech-language pathology, use a communication board, and assess each of the four Appelbaum prongs through whatever modality the patient retains. Declaring incapacity on the basis of communication disability is a board-tested error.

Within the cognitive/psychiatric category — distinguish carefully:

Apparent refusal that is not incapacity:

Key Differentials — Non-Psychiatric and Systemic Causes

— Hypoglycemia (always check glucose first).

— Hypoxia, hypercapnia.

— Hyponatremia, hypernatremia, hypercalcemia.

— Uremia, hepatic encephalopathy.

— Thyroid storm, myxedema coma.

— Sepsis-associated encephalopathy.

— Wernicke encephalopathy — give thiamine before glucose in suspected alcohol use disorder.

— Stroke (especially right MCA with neglect/anosognosia — patients deny their deficits, impairing appreciation).

— Seizure (postictal state, nonconvulsive status epilepticus — consider EEG in unexplained altered mental status).

— Traumatic brain injury, subdural hematoma (especially elderly on anticoagulation after a fall).

— CNS infection (meningitis, encephalitis).

— Alcohol intoxication/withdrawal, opioid intoxication, sedative-hypnotic withdrawal (DTs), stimulant intoxication, anticholinergic toxidrome.

Step 3 management: The "differential for impaired capacity" is essentially the differential for altered mental status. Your workup for an inpatient whose capacity is suddenly in question: fingerstick glucose, vital signs with pulse ox, BMP, calcium, magnesium, LFTs, ammonia (if cirrhosis), TSH, UA, CBC, blood cultures if febrile, medication reconciliation, neuro exam, non-contrast head CT if focal deficits or fall, EEG if unexplained, thiamine 100 mg IV.

Metabolic and systemic causes of acute capacity loss (all potentially reversible):

Neurologic causes:

Toxicologic:

Iatrogenic (revisit): sedatives, opioids, anticholinergics, steroids — review every medication.

Pain itself can transiently impair reasoning; adequate analgesia is a prerequisite to a fair capacity assessment.

Long-Term Plan — Advance Care Planning and Surrogate Designation

— Healthcare proxy / DPOA-HC: legal designation of a surrogate decision-maker; most important single document because it identifies who speaks for the patient.

— Living will: written preferences for specific scenarios (intubation, CPR, artificial nutrition, dialysis).

— POLST/MOLST (Physician/Medical Orders for Life-Sustaining Treatment): a portable medical order signed by a clinician, applicable across care settings (home, ED, SNF, hospital). Distinct from a living will — POLST is an order; a living will is a directive.

— Code status discussion: documented in chart, revisited at admission and at major status changes.

— All adults at primary care visits (Medicare reimburses CPT 99497/99498).

— At diagnosis of serious illness (cancer, advanced HF, COPD GOLD D, ESRD, dementia).

— Before elective surgery in high-risk patients.

— At hospital admission for major illness.

Board pearl: The single most useful intervention to prevent capacity-related crises in a patient with newly diagnosed dementia is to designate a healthcare proxy while capacity is still intact. This is the right answer on countless Step 3 vignettes about Alzheimer's, early HD, ALS, and progressive neurologic disease.

Advance care planning (ACP) is the longitudinal, outpatient-anchored process that prevents most capacity crises. Step 3 emphasizes this proactively.

Components of robust ACP:

When to initiate ACP:

Reassess at every major clinical inflection.

Cultural humility: preferences for who decides (individual vs. family-centered), how much information to disclose, and end-of-life rituals vary; ask, do not assume.

Follow-Up, Reassessment, and Reintegration

— Delirium: reassess daily; capacity often returns within days to weeks after the precipitant clears.

— Severe depression: reassess after 4–8 weeks of treatment; many regain capacity.

— Psychosis on treatment: reassess after stabilization on antipsychotics.

— Acute intoxication: reassess once sober (BAL <80 mg/dL is a reasonable threshold, but clinical assessment trumps numbers).

— Each major decision point requires a fresh, decision-specific assessment.

— Standing "incapacity" labels in the chart are problematic and should be revisited.

— Inform them of decisions made on their behalf.

— Allow them to ratify, modify, or reverse ongoing plans within their now-restored authority.

— Reopen advance care planning while capacity is fresh.

— Primary care for medication reconciliation, deprescribing of agents that contributed.

— Geriatrics or neurology referral if cognitive decline suspected.

— Psychiatry for ongoing mood, psychosis, substance use.

— Social work for surrogate documentation, APS referral, community resources.

Step 3 management: A patient who lacked capacity during a hospitalization for delirium and was placed on warfarin via surrogate consent should, on regaining capacity at discharge follow-up, have a fresh informed-consent conversation about anticoagulation, with the right to continue or decline going forward.

Capacity is dynamic — reassessment is the rule, not the exception.

Documentation cadence:

Restoration of capacity — when an incapacitous patient regains capacity:

Outpatient follow-up after a capacity event:

Counseling family: education that capacity is decision-specific and may return; their role as surrogate is substituted judgment, not "what I want."

Ethical, Legal, and Patient Safety Considerations

— Autonomy (right to make one's own choices, including refusal) vs. beneficence/nonmaleficence (acting in the patient's interest, avoiding harm).

— Capacity assessment is the operationalization of how we balance these — autonomy is honored when capacity is present; beneficence (via surrogate) takes the lead when it is not.

— A patient consents to surgery while sedated on pre-op midazolam → consent invalid; obtain consent before premedication.

— A patient with chronic schizophrenia consents to a research study → ensure decision-specific capacity assessment; consider independent advocate.

— Therapeutic privilege (withholding information believed to be harmful) is rarely justified in modern US practice; almost never the right answer on boards.

— Suspected child abuse, elder abuse, dependent adult abuse → APS/CPS.

— Certain infectious diseases (TB, HIV in some states, STIs, foodborne illnesses) → public health.

— Gunshot wounds, stab wounds, suspected intentional injury → law enforcement (state-dependent).

— Impaired drivers (state-dependent; some states require physician reporting of seizures, dementia).

— Imminent threat to identifiable third party (Tarasoff duty) → warn/protect.

— When an incapacitous patient is transferred between facilities, the surrogate designation, advance directives, and POLST must travel with the chart. Failure to transmit is a top-cited patient safety event.

— Med rec at every transition; identify and discontinue capacity-impairing meds.

Board pearl: A capacitous adult's refusal of treatment must be honored even when the physician disagrees and even when the outcome will be death — as long as the refusal is informed, voluntary, and stable. The only "override" routes are: (1) involuntary psychiatric hold for danger to self/others, (2) court order in narrow circumstances, (3) emergency exception when capacity is absent and no surrogate is available.

Core ethical principles in tension:

Informed consent edge cases tested on Step 3:

Mandatory reporting (overrides confidentiality and patient refusal):

Transition-of-care safety:

High-Yield Associations and Rapid-Fire Clinical Facts

Key distinction: "Refused treatment" alone never answers the boards — the right answer chain is assess capacity → identify and treat reversible causes → involve surrogate or honor refusal → document → reassess.

Capacity = clinical, physician, decision-specific, dynamic. Competence = legal, judge, global, persistent.

Four Appelbaum prongs: Understanding, Appreciation, Reasoning, Choice.

Sliding scale: higher-risk decisions require higher capacity threshold.

MMSE/MoCA scores do not determine capacity by themselves.

Psychiatric diagnosis ≠ incapacity; dementia diagnosis ≠ incapacity.

Disagreement with the physician ≠ incapacity.

Refusal does not require capacity in the same way consent does for low-risk care, but always requires capacity for high-risk refusals.

Jehovah's Witness adult refusing blood with valid advance directive → honor, even in emergency, even unconscious.

Pregnant capacitous adult → may refuse interventions even if fetus at risk.

Pediatric life-threatening refusal by parents → court order (curable leukemia, T1DM, transfusion in trauma).

Emancipated minor / mature minor → can consent independently for contraception, STI, mental health, substance use, pregnancy care in most states.

Healthcare proxy (DPOA-HC) outranks the default surrogate hierarchy.

Substituted judgment > best interests (use best interests only when prior wishes unknown).

POLST is a medical order; living will is a directive.

Two-physician documentation often required for DNR or withdrawal of life-sustaining therapy.

Always rule out reversible causes (delirium, hypoxia, hypoglycemia, meds, pain, sensory deficits) before declaring incapacity.

Tarasoff: duty to warn/protect identifiable third party.

Adult Protective Services: mandatory reporting for suspected elder/dependent adult abuse.

Involuntary psychiatric hold ≠ medical incapacity — separate legal mechanism.

Documentation > determination in malpractice cases — quote the patient, list the four prongs.

Board Question Stem Patterns

Board pearl: When the stem hinges on a patient refusing treatment, your default first move on Step 3 is "perform a decision-specific capacity assessment" — not "call psychiatry," not "call ethics," not "obtain court order."

Stem 1: 78-year-old with mild dementia (MMSE 22) refuses chemotherapy for newly diagnosed colon cancer, citing his age and quality of life. Daughter is upset. → Answer: Assess capacity for this specific decision; if intact, honor refusal, document four prongs. Don't reflexively defer to family.

Stem 2: 45-year-old Jehovah's Witness brought unconscious after MVC with hemorrhagic shock; wallet card refuses blood. → Answer: Honor the advance directive; use alternatives (cell saver, hemostatics, factor concentrates); do not transfuse.

Stem 3: Intoxicated trauma patient with head injury demands to leave AMA. → Answer: Lacks capacity due to intoxication and possible TBI; detain under medical hold, treat, reassess when sober.

Stem 4: 16-year-old requests confidential STI testing without parents' knowledge. → Answer: Provide and maintain confidentiality (state-protected category in nearly all jurisdictions).

Stem 5: Parents of 8-year-old with curable ALL refuse chemotherapy on religious grounds. → Answer: Pursue court order; involve hospital legal/ethics/CPS.

Stem 6: Family of incapacitous ICU patient with no advance directive wants "everything done"; team feels treatment is non-beneficial. → Answer: Family meeting → ethics consult → palliative care; court is rarely the right answer.

Stem 7: Patient with schizophrenia on stable antipsychotic refuses appendectomy for ruptured appendicitis. → Answer: Assess capacity; schizophrenia alone is not incapacity; if appreciation/reasoning intact, honor refusal (and continue trying to persuade).

Stem 8: Newly diagnosed early Alzheimer's, asking about future planning. → Answer: Designate healthcare proxy now, complete advance directive/POLST while capacity intact.

Stem 9: Inpatient with new-onset confusion refusing antibiotics; CAM positive, on diphenhydramine and oxycodone. → Answer: Hold offending meds, treat delirium, reassess capacity; do not force treatment immediately if non-emergent.

One-Line Recap

Capacity is a decision-specific, dynamic, physician-made clinical judgment about whether a patient can understand, appreciate, reason about, and communicate a choice regarding a particular medical decision — fundamentally distinct from competence, which is a global, judge-made legal status.

Board pearl: On Step 3, the highest-yield single intervention for any patient with progressive cognitive disease is early designation of a healthcare proxy while capacity is intact — this single action prevents the majority of downstream surrogate conflicts and honors patient autonomy across the trajectory of illness.

Capacity vs. competence: Clinical/physician/decision-specific/dynamic vs. legal/judge/global/persistent — never conflate these on the boards.

The four Appelbaum prongs — Understanding, Appreciation, Reasoning, Choice — are the structured framework; use direct patient quotes for each in your documentation.

Always rule out reversible causes first — delirium, hypoxia, hypoglycemia, pain, sensory deficits, capacity-impairing medications (benzodiazepines, opioids, anticholinergics, steroids), and intoxication — before locking in an "incapacity" determination for any non-emergent decision.

When capacity is absent, follow the cascade: advance directive → substituted judgment by healthcare proxy or surrogate per state hierarchy → best interests; invoke the emergency exception only when no surrogate is available and the threat is immediate; pursue ethics consultation for conflict and court orders only as a last resort or for pediatric life-threatening parental refusals.