Behavioral Health

Capacity assessment for medical decisions

Clinical Overview and When to Suspect Impaired Capacity

— Communicate a choice (and maintain it with reasonable stability)

— Understand the relevant information (diagnosis, proposed treatment, alternatives, risks/benefits)

— Appreciate how the information applies to one's own situation (insight that "this is happening to me")

— Reason through options in a way consistent with one's values

— Refusal of clearly beneficial, low-risk treatment (e.g., antibiotics for sepsis) without coherent rationale

— Acute mental status change: delirium, intoxication, hypoxia, hypoglycemia, sepsis, opioid use

— Underlying dementia, intellectual disability, psychosis, severe depression, mania

— Stroke (especially nondominant hemisphere with anosognosia), TBI, hepatic/uremic encephalopathy

— Communication barriers masking comprehension (language, hearing, aphasia)

— Decision is highly inconsistent with the patient's prior stated values

Board pearl: Agreeing with the physician is never evidence of capacity, and disagreeing is never evidence of incapacity. The Step 3 trap is the "difficult" patient who refuses care — assess the process of decision-making, not the outcome.

Key distinction: Capacity = clinical, by any physician. Competence = legal, by a court.

Decision-making capacity is a clinical judgment about whether a patient can make a specific medical decision at a specific time — it is not the same as competence (a legal determination by a judge).

Capacity is decision-specific and time-specific: a patient may have capacity to choose a meal but not to refuse dialysis; capacity to consent to a low-risk blood draw but not to refuse cardiac surgery.

The four pillars (Appelbaum & Grisso framework) — every Step 3 stem will test at least one:

When to suspect impaired capacity:

Sliding scale principle: the threshold for capacity rises with the risk/benefit asymmetry of the decision. A patient refusing aspirin needs less demonstrated capacity than one refusing emergency craniotomy.

Presentation Patterns and Key History

— Elderly patient with possible dementia refusing nursing home placement or surgery

— Psychiatric patient (schizophrenia, bipolar mania, severe MDD) refusing or demanding treatment

— Intoxicated trauma patient refusing CT or wanting to leave AMA

— Postoperative or ICU patient with hypoactive delirium signing forms

— Adolescent or developmentally disabled adult and questions of assent vs consent

— Jehovah's Witness refusing blood — typically has capacity; values-based refusal is not incapacity

— Anorexia nervosa patient refusing nutrition — capacity often impaired due to appreciation deficit

— Baseline cognition: prior MMSE/MoCA, ADLs/IADLs, collateral from family or PCP

— Acute precipitants: new meds (benzodiazepines, anticholinergics, opioids), infection, electrolyte derangements, substance use

— Psychiatric history: known illness, current symptoms, suicidality, command hallucinations

— Advance directives, healthcare proxy, prior expressed wishes, religious/cultural values

— Educational level and primary language — always use a certified medical interpreter, not family

— "The cancer isn't real, the doctors planted it"

— "God will heal me, I don't need surgery" stated as new belief inconsistent with prior practice

— Concrete denial: "I don't have diabetes" despite glucose 480 and prior insulin use

— Inability to restate the choice consistently over hours

Step 3 management: Begin every capacity evaluation by treating reversible causes first — correct hypoxia, hypoglycemia, electrolytes, pain, urinary retention, and review the medication list. Many "incapacitated" inpatients regain capacity once delirium clears, and a premature surrogate decision is a documentation and liability problem.

Board pearl: If the patient cannot consistently state a choice across two interviews several hours apart, communication of choice is failing — capacity is absent.

Typical Step 3 vignette triggers for a capacity question:

History to obtain (and document):

Red flags suggesting impaired appreciation/reasoning:

Physical Exam Findings and the Bedside Capacity Interview

— Vitals: hypoxia, fever, hypotension, hypertensive encephalopathy

— Neuro: level of consciousness, attention (months backward, days of week backward, serial 7s), focal deficits, aphasia screen

— Signs of delirium: fluctuating attention, disorganized thinking, altered consciousness (CAM criteria)

— Stigmata of intoxication or withdrawal (tremor, diaphoresis, nystagmus, miosis/mydriasis)

— Hearing aids in place? Glasses available? Interpreter present?

— MoCA (sensitive for mild cognitive impairment, scored /30; <26 abnormal)

— MMSE (less sensitive for executive dysfunction)

— CAM for delirium screen

— Aid to Capacity Evaluation (ACE) — semi-structured tool aligned with the four pillars

— Disclose the diagnosis in plain language, then ask the patient to paraphrase it

— Disclose the proposed treatment, alternatives (including no treatment), risks, and benefits

— Ask: "What do you think will happen if you choose this option? If you choose nothing?"

— Ask: "Why are you making this choice? What matters to you?"

— Confirm the choice; revisit in hours if stability is in doubt

CCS pearl: On a CCS case, if the patient is altered, order "capacity evaluation" along with workup for the reversible cause (CBC, BMP, UA, ABG, glucose, head CT if indicated). Don't jump straight to "consult psychiatry" — any physician can assess capacity; psychiatry consult is reserved for ambiguous or psychiatrically complex cases.

Key distinction: Cognitive impairment ≠ incapacity. A patient with mild dementia (MoCA 22) can often still consent to routine care.

General exam priorities before declaring incapacity:

Structured bedside tools (use, but never as a sole determinant):

The capacity interview itself — Step 3 expects this sequence:

A patient with fluctuating attention cannot complete this interview reliably — defer the assessment until the delirium resolves rather than declare permanent incapacity.

Diagnostic Workup — Identifying Reversible Contributors

— CBC (infection, anemia causing hypoxia)

— BMP (sodium, calcium, BUN/creatinine — uremia, hyponatremia common culprits)

— Glucose, fingerstick first (hypoglycemia is the fastest reversible cause)

— LFTs and ammonia if cirrhosis suspected (hepatic encephalopathy)

— TSH for myxedema in chronic confusion

— B12, folate in elderly cognitive change

— Urinalysis — UTI is the classic delirium trigger in elderly women

— Urine drug screen and ethanol level in trauma, ED, AMA cases

— ABG/VBG for hypoxia, hypercapnia, acidosis

— ECG if syncope or arrhythmia could underlie hypoperfusion

— Medication reconciliation: benzodiazepines, opioids, anticholinergics (diphenhydramine, oxybutynin, TCAs), steroids, fluoroquinolones, gabapentinoids

— Non-contrast head CT for focal deficits, fall, anticoagulation, or unexplained acute change

— MRI brain for subacute cognitive decline or suspected stroke

— Suspected NPH triad (gait, urinary incontinence, cognitive decline) → brain MRI

— Rapidly progressive dementia → consider CJD workup, autoimmune encephalitis panel, paraneoplastic

— New psychosis in elderly → rule out delirium before attributing to primary psychiatric illness

Step 3 management: A patient refusing recommended care with acute altered mental status should not be allowed to sign out AMA until the reversible workup is complete. Document the capacity assessment and the medical decision-making at that moment in time.

Board pearl: UTI and polypharmacy together account for a substantial share of "lost capacity" cases in hospitalized elderly — fix these before invoking a surrogate.

Capacity assessment is fundamentally clinical, but the workup of a patient with newly impaired capacity targets reversible medical contributors. Standard initial panel:

Imaging when indicated:

Special situations:

Diagnostic Workup — Formal Capacity Tools and Psychiatric Consultation

— MacArthur Competence Assessment Tool for Treatment (MacCAT-T): gold standard for research and complex cases; semi-structured, scores each of the four pillars separately

— Aid to Capacity Evaluation (ACE): free, validated, faster — good for busy inpatient settings

— Mini-Cog or MoCA: screening for cognitive impairment, not capacity itself

— Disagreement between treating team and family/surrogate

— Patient with psychiatric illness where symptoms may distort appreciation (psychotic denial of illness, severe depression with nihilism, mania with grandiosity)

— High-stakes refusal of life-sustaining treatment by a marginally capacitated patient

— Suspected coercion, undue influence, or elder abuse

— Repeat assessments yielding inconsistent results

— The specific decision in question

— Information disclosed to the patient (diagnosis, treatment, alternatives, risks)

— Patient's responses regarding each of the four pillars (with quotes when possible)

— Conclusion: capacity present or absent, for this decision, at this time

— Plan: who is the surrogate, or when will capacity be reassessed

Key distinction: A psychiatric diagnosis (even schizophrenia or dementia) does not automatically equal incapacity. You must still test the four pillars for the specific decision.

CCS pearl: Order "psychiatry consultation" only after attempting your own structured capacity assessment and addressing reversible causes — premature consults lose points on management efficiency.

When to use a structured instrument (and which one):

When to consult psychiatry (or ethics):

Psychiatry's role: to assist the primary team's capacity determination — not to override it. The treating physician remains responsible for the decision.

Documentation requirements (commonly tested):

A capacity note that simply states "patient lacks capacity" without the four-pillar analysis is legally and clinically inadequate.

Risk Stratification — The Sliding Scale and Decisional Threshold

— Low-stakes decision + concordant with medical advice → low threshold; minimal demonstration suffices (e.g., accepting routine flu shot)

— Moderate-stakes decision → standard four-pillar assessment

— High-stakes decision + refusal of life-saving treatment → highest threshold; rigorous appreciation and reasoning required

— Emergency (immediate threat to life/limb, no time for full assessment): proceed under implied consent / emergency exception; document why delay was unsafe

— Urgent (hours): rapid bedside assessment, treat reversible causes in parallel, involve surrogate if needed

— Elective (days–weeks): formal assessment, optimize cognition, involve family, consider ethics consult

— Court-appointed guardian (if exists)

— Healthcare power of attorney (durable POA for healthcare)

— Spouse

— Adult children (majority rule among them)

— Parents

— Adult siblings

— Other relatives or close friend

Board pearl: The classic stem — patient with mild dementia refuses a low-risk procedure → assess capacity but default to respecting refusal unless clear incapacity. Autonomy is the dominant principle when capacity is intact.

Step 3 management: Always ask, "Is there a healthcare proxy document on file?" before defaulting to next-of-kin.

The sliding scale of capacity (Drane's model) is foundational on Step 3:

The asymmetry rule: the same patient may have capacity to consent to a treatment but not to refuse it, because refusal of a life-saving intervention carries higher consequences and demands clearer reasoning.

Stratifying urgency of the capacity decision:

Who is the surrogate when capacity is absent? US default hierarchy (varies by state — Step 3 tests the common order):

Surrogates must use substituted judgment (what the patient would have wanted based on prior values) first; only if unknown do they fall back on best interests.

Management — When Capacity Is Present vs Absent

— Respect the decision, even if the physician disagrees

— Continue to explore concerns; reframing, additional information, or addressing fears may change a refusal

— Document the informed refusal with risks discussed and patient's verbalized understanding

— Offer alternatives (e.g., outpatient follow-up if refusing admission), schedule follow-up, provide return precautions

— Do not threaten, coerce, or withhold unrelated care

— Identify and treat reversible contributors aggressively (delirium bundle, medication adjustment, pain control)

— Identify the surrogate decision-maker per state hierarchy

— Provide the surrogate the same disclosure you would the patient

— Ask the surrogate to apply substituted judgment based on the patient's prior values and any advance directive

— Continue to involve the patient at their level of ability (assent), even when consent is via surrogate

— Reassess capacity periodically — it can return

— Two-physician consensus for non-emergent treatment in some states

— Ethics committee review

— Court-appointed guardian for prolonged decisions

— Emergency exception covers immediate life-saving care regardless

— Avoid chemical or physical restraints unless imminent harm; they do not restore capacity and carry FDA black-box risks in dementia (antipsychotics increase mortality)

— Use nonpharmacologic delirium management first: reorientation, sleep-wake cycle, mobilization, glasses/hearing aids, family at bedside

CCS pearl: When you check "patient lacks capacity," your next CCS orders should include "identify surrogate decision-maker," "treat underlying cause," "delirium precautions," and "reassess capacity daily."

Board pearl: Antipsychotics for delirium do not improve outcomes and may worsen them; use only for severe agitation threatening safety.

Capacity present:

Capacity absent — algorithm:

No available surrogate? Options depend on state law:

Special therapeutic considerations:

Special Scenarios — AMA, Refusal of Blood, Anorexia, Suicidal Patients

— Must perform and document capacity assessment before signing

— Disclose specific risks (death, disability, complications) in lay language

— Provide prescriptions, follow-up, return precautions — never withhold these as punishment

— Intoxicated patients almost never have capacity to leave AMA; observe until sober and reassess

— Adults with capacity may refuse blood even if life-threatening — autonomy prevails

— Confirm decision is the patient's own (not coerced), private interview without family

— Document specific products refused (some accept albumin, cell saver, EPO)

— Minors: court order can override parental refusal of life-saving transfusion

— Often lacks appreciation ("I'm not too thin") — capacity frequently impaired

— Involuntary treatment (including involuntary hold, NG feeding) may be justified

— Active suicidality with plan = involuntary hold (state-specific: 72-hour "5150"-type laws)

— Does not require formal capacity finding — separate legal mechanism for danger to self/others

— Maternal autonomy generally prevails; courts have largely rejected forced cesarean delivery

— Having capacity does not entitle a patient to receive non-indicated care

— Physician autonomy and stewardship apply — decline respectfully, explain rationale

Key distinction: Refusing care because of values (religion, lifestyle) is not incapacity. Refusing care because of a distorted perception of reality (psychosis, severe depression, anosognosia) is.

Step 3 management: Document that AMA discharge included capacity assessment, risk disclosure, prescriptions given, and follow-up arranged — all four are tested.

Against Medical Advice (AMA) discharge:

Jehovah's Witnesses refusing transfusion:

Anorexia nervosa refusing nutrition:

Suicidal patient refusing psychiatric admission:

Pregnant patient refusing intervention:

Patient demanding non-indicated treatment (e.g., antibiotics for viral URI, opioids):

Special Populations — Elderly and Cognitive Impairment

— MoCA 18–25 does not automatically equal incapacity

— Many patients retain capacity for routine and even significant decisions

— Use enhanced disclosure: simpler language, written materials, repeat sessions, involve family with patient's permission

— Reassess capacity for each new significant decision (don't extrapolate)

— Capacity for complex medical decisions usually absent

— May retain capacity for simple preferences (food, activity, presence of family)

— Surrogate decision-making the norm — advance directive ideal

— Best time of day (avoid sundowning)

— Hearing aids, glasses, dentures

— Quiet environment, no distractions

— Adequate pain control (untreated pain mimics dementia in elderly)

— Review meds — Beers Criteria: avoid benzos, anticholinergics, sedating antihistamines

— Uremia and hepatic encephalopathy cause fluctuating capacity — reassess after dialysis or lactulose

— Avoid renally cleared sedatives that prolong cognitive impairment

— Discuss code status, POLST/MOLST forms, healthcare proxy at every transition of care

— Medicare reimburses advance care planning discussions (CPT 99497) — Step 3 health systems content

— Goals-of-care conversations are part of routine outpatient care, not just end-of-life

Board pearl: A POLST/MOLST is a portable medical order signed by a clinician and follows the patient across settings; an advance directive is a legal document expressing wishes. POLST is actionable; advance directive guides interpretation.

Step 3 management: At every elderly hospital discharge, confirm or update healthcare proxy and code status on the discharge summary — a measurable transitions-of-care quality metric.

Mild cognitive impairment and early dementia:

Moderate to severe dementia (MoCA <15, advanced ADL loss):

Optimize before assessment:

Renal/hepatic impairment:

Advance care planning in geriatrics:

Special Populations — Minors, Adolescents, and Developmental Disability

— Parents/guardians provide consent; minors provide assent when developmentally able

— Confidentiality should still be respected to extent possible

— Adolescents demonstrating decision-making capacity for specific decisions may consent independently

— Common when parents are unavailable for time-sensitive decisions

— Contraception and reproductive health

— STI testing and treatment

— Pregnancy care

— Substance use treatment

— Mental health (varies by state and age)

— Disclose limits of confidentiality upfront: harm to self, harm to others, abuse

— Life-saving treatment: courts generally side with treatment

— Elective treatment: parental consent generally required, but mature minor may have weight

— Diagnosis alone ≠ incapacity

— Assess capacity for the specific decision using simplified language, pictures, repetition

— Many adults with mild–moderate ID retain capacity for many decisions

— Guardianship (full or limited) may exist — review legal documents for scope

— Supported decision-making is the modern preferred alternative to guardianship where feasible

Key distinction: Assent (agreement by a minor or person without full capacity) is ethically essential but legally insufficient — adult consent (parent, guardian, or surrogate) is still required.

Board pearl: A 16-year-old can usually consent to STI testing and contraception without parental notification — confidentiality is a federal/state-protected service line tested frequently.

Minors (under 18) — general rule:

Mature minor doctrine (state-dependent):

Emancipated minors (married, military, financially independent, parenting, by court order) consent as adults

Confidential care for adolescents (federally and state-protected in most states):

Disagreements between parents and adolescents:

Intellectual and developmental disability:

Autism spectrum: communication differences are not capacity deficits; allow extra time and concrete framing.

Complications — Errors in Capacity Assessment

— Patient agrees with the team, so no assessment is done → "agreement bias"

— Surface fluency masks impaired appreciation in early dementia or psychosis

— Result: invalid consent, treatment without true authorization, potential battery claim, harm from poorly understood treatment

— Patient disagrees with the team → "disagreement bias"

— Cognitive screen low but reasoning intact for specific decision

— Result: violation of autonomy, possible battery/false imprisonment, ethical breach, loss of trust

— Using MMSE/MoCA score as a sole capacity threshold

— Assessing capacity globally rather than decision-specifically

— Failing to reassess after reversible cause treated

— Allowing family to override a capacitated patient's wishes

— Failing to use an interpreter — comprehension cannot be assessed in a language the patient does not speak fluently

— Wrong surrogate identified → wrong decision made

— Patient eloped from hospital after invalid AMA → poor outcome

— Restraints used in lieu of capacity assessment → injury, deconditioning, deeper delirium, aspiration

— Antipsychotics for "agitation" without delirium workup → falls, prolongation of delirium, increased mortality in dementia

Step 3 management: When a patient's stated choice changes between assessments, do not assume malingering or stable incapacity — investigate for fluctuating delirium, intermittent psychosis, or new medications.

Board pearl: The phrase "patient is a poor historian" without a capacity note is a red flag for a documentation gap that will be probed on QI/peer review.

False positives (declaring capacity when absent):

False negatives (declaring incapacity when present):

Common pitfalls:

Adverse clinical outcomes from poor process:

Documentation failures are the leading source of medicolegal exposure — a structured four-pillar note is protective.

When to Escalate — Ethics, Legal, and Specialist Consultation

— Suspected primary psychiatric illness affecting capacity

— Severe depression with treatment refusal

— Psychotic features distorting appreciation

— Diagnostic uncertainty about delirium vs primary psychiatric disorder

— Complex pediatric/adolescent capacity questions

— Disagreement between team and family or among family members

— No identifiable surrogate and non-emergent decision needed

— Conflict about goals of care, withholding/withdrawing treatment

— Suspected coercion or undue influence

— Moral distress among team members

— Anticipated court petition for guardianship

— Allegations of patient incapacity in setting of significant new financial or legal decisions

— Refusal of life-saving treatment by marginally capacitated patient

— Suspected elder abuse, intimate partner violence, child abuse — also triggers mandatory reporting

— Emergency guardianship for prolonged incapacity with no surrogate and high-stakes decision

— Override of parental refusal of life-saving treatment for minor

— Disputes among potential surrogates of equal standing

— Delirium not responding to standard measures → consider ICU for closer monitoring, especially with autonomic instability

— Severe agitation threatening staff/self → 1:1 sitter before chemical restraint

— Persistent suicidality → involuntary psychiatric hold per state statute

CCS pearl: On a CCS case, "ethics consultation" is appropriate when surrogate and team disagree, but should not be ordered before attempting direct discussion with the family — communication failure precedes most ethics consults.

Key distinction: Ethics consults advise; they do not decide. The attending physician remains responsible for the medical decision.

Psychiatry consultation indications:

Ethics consultation indications:

Risk management/legal consultation:

Court involvement (rare, last resort):

Inpatient escalation:

Differentials — Causes of Apparent Incapacity Within Behavioral Health

— Acute onset, fluctuating, inattention, disorganized thinking

— Hypoactive form (lethargy, withdrawal) is more common and more often missed than hyperactive

— Capacity typically returns with treatment of underlying cause

— Insidious, progressive, multiple domains

— Capacity may be preserved for simple decisions, lost for complex

— Alzheimer, vascular, Lewy body, frontotemporal, mixed

— Severe depression can produce nihilistic distortion ("I deserve to die," "nothing will help")

— Treatment of depression may restore capacity for treatment decisions

— Depression alone is not automatic incapacity

— Schizophrenia, schizoaffective, brief psychotic disorder

— Capacity impaired when delusions or hallucinations directly distort appreciation of illness/treatment

— Patient with stable schizophrenia on medication often has full capacity for routine care

— Grandiosity, impaired judgment, distractibility impair reasoning

— Capacity often impaired during acute mania; restored with treatment

— Acute alcohol or sedative intoxication impairs all four pillars

— Withdrawal delirium (DTs) is a medical emergency and impairs capacity

— Reassess when sober

— Generally do not impair capacity, even when distressing or making decisions difficult to navigate

Board pearl: Hypoactive delirium in an elderly inpatient is the most under-recognized cause of "absent capacity" — quiet withdrawal is not the same as quiet acceptance.

Delirium (most common reversible cause in hospital):

Major neurocognitive disorder (dementia):

Major depressive disorder:

Psychotic disorders:

Bipolar disorder, manic phase:

Substance intoxication/withdrawal:

Anxiety disorders, personality disorders:

Differentials — Medical and Neurologic Mimics

— Hypoglycemia, hyponatremia, hypercalcemia, uremia, hepatic encephalopathy

— Thyroid (myxedema, thyroid storm)

— Vitamin deficiencies: B12, thiamine (Wernicke), folate

— UTI, pneumonia, bacteremia in elderly often present primarily as altered mentation

— Meningitis, encephalitis (HSV, autoimmune)

— Neurosyphilis, HIV-associated neurocognitive disorder

— Stroke (especially right hemisphere → anosognosia, denial of deficit, impairs appreciation)

— Subdural hematoma (elderly, anticoagulated, falls)

— Brain tumor — frontal lesions impair executive function and judgment disproportionately

— Normal pressure hydrocephalus (gait, cognition, incontinence)

— Postictal state — wait for resolution before assessing capacity

— Nonconvulsive status epilepticus presents as prolonged altered mental status; EEG diagnostic

— Opioids, benzodiazepines, anticholinergics (oxybutynin, diphenhydramine, TCAs)

— Steroid psychosis

— Fluoroquinolone-associated delirium

— Anesthesia recovery, ICU sedation

Step 3 management: Right MCA stroke with anosognosia → patient denies hemiparesis and refuses rehab. Capacity for the refusal is impaired due to lack of appreciation, even though communication, understanding, and reasoning may appear superficially intact. Engage surrogate; reassess as insight improves.

Key distinction: A patient who cannot speak but can write, point, or nod consistently to questions may still demonstrate capacity — language ≠ cognition.

Toxic-metabolic:

Infectious:

Structural neurologic:

Seizure-related:

Iatrogenic:

Aphasia (especially Wernicke): comprehension impaired but capacity for choice may be preserved with alternative communication (writing, pictures, communication boards)

Pseudodementia of depression: cognitive complaints with intact actual cognition once depression treated

Secondary Prevention — Advance Care Planning and Long-Term Strategy

— Healthcare power of attorney (HCPOA / durable POA for healthcare): names a surrogate decision-maker; activates upon incapacity

— Living will: specifies wishes regarding life-sustaining treatment (ventilation, CPR, artificial nutrition, dialysis)

— POLST/MOLST: portable medical order signed by clinician; actionable in any setting including EMS

— DNR/DNI orders: specific to resuscitation; should be reaffirmed at each admission

— New diagnosis of serious illness (cancer, advanced heart failure, COPD GOLD D, ESRD, dementia)

— Routine annual visit in older adults (Medicare reimburses CPT 99497/99498)

— Every hospitalization, especially ICU admissions

— Transitions of care: nursing home admission, hospice enrollment

— Choose someone willing to honor your values, even if different from theirs

— Communicate values explicitly — "What matters most if you couldn't speak for yourself?"

— Provide written documents to surrogate, PCP, and chart

— Early dementia: capacity intact for advance directive; window closes as disease progresses

— ALS: plan for ventilation, gastrostomy, communication device before bulbar progression

— Advanced cancer: discuss goals before crises (e.g., recurrent admissions)

— Five Wishes document — accepted in most states, covers medical and personal preferences

— State-specific forms available; verify validity across state lines

Step 3 management: At every Medicare wellness visit and every chronic disease follow-up, screen for advance directive status and offer the discussion. This is a measured quality metric (e.g., MIPS) and a Step 3 health systems/value-based care theme.

Board pearl: POLST is a medical order; advance directive is a legal document. EMS follows POLST.

Goal: prevent future capacity crises by planning while capacity is intact.

Components of advance care planning:

When to initiate (and reaffirm):

Surrogate selection counseling:

Disease-specific planning:

Special instruments:

Follow-Up, Monitoring, and Counseling After Capacity Events

— Reassess and document return of capacity

— Revisit decisions made under surrogate consent — patient may now want to change course

— Provide patient with information about the period of incapacity (what was decided, by whom)

— Address potential PTSD symptoms after ICU delirium — common, under-recognized

— Confirm surrogate is engaged and informed at each visit

— Update POLST as disease progresses and goals shift

— Coordinate hospice/palliative care referral when appropriate

— Monitor caregiver burden — Zarit Burden Interview; refer to support services

— Discharge summary must include: capacity status at discharge, surrogate name and contact, advance directive on file, code status

— Communicate with PCP within 48 hours of discharge for high-risk patients (CMS readmission reduction)

— Schedule follow-up within 7–14 days for medication-complex discharges

— For patients refusing care despite capacity: motivational interviewing, exploration of fears, offer staged plans (trial of treatment, partial intervention)

— For families of incapacitated patients: educate on substituted judgment, dispel guilt around end-of-life decisions, reassure that decisions can evolve

— For caregivers: respite care, support groups, recognition of burnout

— Documentation of code status on admission and discharge

— Advance directive on file for patients >65

— 30-day readmission rate after AMA discharge

CCS pearl: On the final screen, your discharge plan should include "follow-up with PCP in 1–2 weeks," "advance directive reviewed," and "patient education provided" — these score for transitions-of-care completeness.

Key distinction: Caregiver fatigue can drive a surrogate toward decisions that don't reflect the patient's prior values — recognize and offer support.

For patients with restored capacity (post-delirium, sobriety, treated depression):

For patients with permanent or progressive incapacity (dementia, severe TBI):

Discharge transitions of care:

Counseling content:

Quality metrics (Step 3 health systems):

Ethical, Legal, and Patient Safety Considerations

— Autonomy (right to self-determination) vs beneficence (acting in patient's best interest) vs nonmaleficence (do no harm) vs justice (equitable allocation)

— Capacity assessment is the gateway that determines whether autonomy or surrogate-mediated beneficence governs

— Therapeutic privilege (withholding information believed to harm patient): exceptionally narrow; rarely justified

— Waiver of consent: patient may decline to receive information and delegate to physician/surrogate — must be documented as an active choice

— Emergency exception: consent presumed when delay would cause death/serious harm and patient cannot consent

— Suspected child abuse, elder abuse, dependent adult abuse — report regardless of capacity findings

— Certain communicable diseases (TB, syphilis, HIV in many states)

— Gunshot/stab wounds, suspected impaired drivers (state-specific)

— Threats of harm to identifiable third parties (Tarasoff duty)

— Even an incapacitated patient retains privacy rights; share only relevant information with surrogate

— Adolescent confidential services persist even if parents are involved in other aspects of care

— AMA discharge without capacity assessment is a sentinel-event-level documentation failure

— Code status not communicated at handoff is a high-risk transitions-of-care error

— Restraints (chemical or physical) without indication and reassessment violate CMS Conditions of Participation

— Financial elder abuse: new will, new POA in a patient with cognitive decline — escalate to social work, APS

— Family pressure to override patient's wishes — interview patient alone

Board pearl: Tarasoff: if a patient with apparent capacity makes a credible threat against an identifiable victim, the duty to warn/protect overrides confidentiality — a frequent Step 3 ethics stem.

Step 3 management: Suspected elder abuse in a patient with impaired capacity — report to APS and document; do not delay reporting pending capacity workup.

Core ethical principles in tension:

Informed consent edge cases:

Mandatory reporting (always tested):

Confidentiality and capacity:

Patient safety and transitions of care:

Coercion concerns:

High-Yield Associations and Rapid-Fire Clinical Facts

Board pearl: "Patient has capacity to refuse" is a complete clinical answer only when paired with documented four-pillar reasoning, risks disclosed, and follow-up offered.

Key distinction: A capacitated refusal of life-sustaining treatment is not suicide and does not justify involuntary hold.

Capacity is decision-specific, time-specific, and clinical — competence is global and legal

Any physician can assess capacity — psychiatry is consulted for complexity, not by default

The four pillars: Communicate, Understand, Appreciate, Reason

Sliding scale: higher stakes → higher threshold for demonstrating capacity

Agreement ≠ capacity; disagreement ≠ incapacity

Reversible causes of impaired capacity: DELIRIUMS — Drugs, Electrolytes, Lack of drugs (withdrawal), Infection, Reduced sensory input, Intracranial, Urinary/fecal, Myocardial/pulmonary, Sleep deprivation

MoCA <26 suggests cognitive impairment but does not diagnose incapacity

Hypoactive delirium > hyperactive in frequency, and more often missed

Right MCA stroke → anosognosia → impaired appreciation

Anorexia nervosa — often lacks appreciation; involuntary treatment may be justified

Jehovah's Witness adult — refusing transfusion with capacity is autonomy, not incapacity

Pregnant patient — autonomy generally prevails; cannot force cesarean

Minor exceptions (consent without parents): emergency, emancipation, mature minor, confidential services (STI, contraception, pregnancy, substance use, often mental health)

POLST = portable medical order; advance directive = legal document

Substituted judgment > best interests when prior values are known

Surrogate hierarchy default: guardian → HCPOA → spouse → adult children → parents → siblings

Tarasoff duty overrides confidentiality for credible threat to identifiable victim

Antipsychotics increase mortality in dementia (black box) — avoid for non-emergent agitation

Suspected abuse → mandatory report, regardless of capacity status

Two-physician consensus allowed in some states when no surrogate available for non-emergent care

Board Question Stem Patterns

Step 3 management: Look for the phrase "the patient consistently states…" — the consistency of the choice is a clue that communication of choice pillar is being tested.

Board pearl: When the answer choice includes "psychiatry consult," ask whether the primary team has completed its own four-pillar assessment first — premature consultation is rarely the best answer.

Stem 1 — Elderly refusing surgery: 78-year-old with mild dementia (MoCA 23) refuses hip fracture repair, states "I've lived a good life." Family insists on surgery. Answer: Assess capacity using four pillars; if intact for this decision, respect refusal; offer palliative care, pain control, family meeting.

Stem 2 — AMA in intoxicated patient: 35-year-old after MVC with BAC 240 wants to leave before CT. Answer: Lacks capacity due to intoxication; detain for medical evaluation until sober; reassess capacity; do not allow AMA signature now.

Stem 3 — Jehovah's Witness: 40-year-old with GI bleed, Hgb 5, refuses transfusion. Answer: Confirm capacity (private interview, four pillars, prior values consistent); respect refusal; offer alternatives (IV iron, EPO, cell saver); document thoroughly.

Stem 4 — Schizophrenia and somatic illness: 50-year-old with chronic schizophrenia on medication needs appendectomy, agrees coherently. Answer: Has capacity; psychiatric diagnosis does not equal incapacity; proceed with informed consent.

Stem 5 — Right MCA stroke: Patient denies left arm weakness, refuses rehab. Answer: Anosognosia impairs appreciation; capacity absent for this decision; involve surrogate; reassess.

Stem 6 — Anorexia refusing nutrition: BMI 13, refuses NG feeding, denies being too thin. Answer: Appreciation impaired; capacity absent for nutritional refusal; involuntary treatment justified.

Stem 7 — Suicidal patient: Active plan, refusing admission. Answer: Involuntary psychiatric hold; separate from capacity assessment.

Stem 8 — Adolescent confidential care: 16-year-old requests STI testing without parental notification. Answer: Provide confidentially; this is protected service.

Stem 9 — Tarasoff: Patient credibly threatens identifiable person. Answer: Duty to warn/protect overrides confidentiality.

Stem 10 — Surrogate disagreement: Adult children disagree on ventilator withdrawal for parent in PVS. Answer: Family meeting, ethics consult, substituted judgment based on patient's prior values; if unresolved, court.

One-Line Recap

Capacity is a decision-specific, time-specific clinical judgment — assessed by any physician using the four pillars (Communicate, Understand, Appreciate, Reason) on a sliding scale calibrated to the risk of the decision — and when absent, decisions devolve to a surrogate using substituted judgment, never overriding a capacitated patient's autonomy even when the choice is high-risk.

Board pearl: Capacity is the gateway between autonomy and surrogate-mediated beneficence — get the gate right and the rest of the ethical decision follows.

Step 3 management: At every transition of care, confirm capacity status, surrogate identification, advance directive, and code status — these four data points define safe, ethically sound handoffs.

The four pillars: Communicate a stable choice; Understand information disclosed; Appreciate that it applies to oneself; Reason through alternatives consistent with one's values

Sliding scale: higher-stakes refusals require higher demonstrated capacity; agreement with the team is never proof of capacity, and disagreement is never proof of incapacity

Reversible first, surrogate second: treat delirium drivers (UTI, electrolytes, meds, hypoxia, hypoglycemia, pain) before declaring durable incapacity, and reassess as the patient improves

Surrogate hierarchy and substituted judgment: guardian → HCPOA → spouse → adult children → parents → siblings; surrogates apply the patient's prior values first, best interests only when values are unknown

Special cases: Jehovah's Witness adults with capacity may refuse blood; anorexia and right MCA stroke commonly impair appreciation; intoxicated and acutely psychotic patients lack capacity for AMA; adolescents have protected confidential services for sexual, reproductive, mental health, and substance use care

Documentation discipline: capacity note must specify the decision in question, information disclosed, four-pillar findings (with quotes), conclusion, and plan — this protects the patient, the team, and the record