A 74 year old female with a GI bleed is refusing treatment, stating that she just wants to go home rather than being transfused for her hemoglobin is 5. You attempt to convince her to stay but she steadfastly says that she just wants to leave. She mentions she has to feed her dog and she wants to sleep in her own bed. What do you do next?

Calling psychiatry to determine capacity to make medical decisions seems like our default answer in the ED but emergency medicine physicians are actually capable of determining themselves if a patient has decision making capacity. Any physician responsible for caring for a patient can determine if a patient possesses capacity, and research comparing psychiatrists’ judgments to those of other physicians shows that they are no better at assessing capacity in practice.

To determine if a patient has decisional capacity, a physician must assess 4 specific capabilities:

  • Ability to understand information relevant to treatment decisions
  • Ability to appreciate the significance of the information
  • Ability to weigh treatment options and demonstrate reasoning
  • Ability to express a choice

A formal, structured assessment tool can be used to evaluate capacity. Two such tools are the Aid to Capacity Evaluation (ACE) and the MacArthur Competence Assessment Tool (MacCAT); the ACE is shorter and more clinically oriented. Both use standardized questions and scoring systems to achieve a more objective assessment of capacity although the abilities assessed are the same as above and still require interpretation by the evaluator.

Finally, it’s important to remember that Western culture both legally and ethically values patient autonomy and that any restriction requires a clear and convincing assessment that a patient’s decision regarding care will result in unintended, irreparable harm.

Thanks to Dr. Andrus for serving as the inspiration for this post!

Sessums LL, Zembrzuska H, Jackson JL. Does This Patient Have Medical Decision-Making Capacity? JAMA. 2011;306(4):420-427.
Markson LJ, Kern DC, Annas GJ, Glantz LH. Physician assessment of patient competence. J Am Geriatr Soc. 1994;42:1074–80.