Assessment tools may be helpful in the assessment of decisional capacity, particularly in high-risk settings. There is no evidence to establish a single tool as a valid gold standard for assessment of capacity, and the utilization of any of these assessment tools represents only one part of the clinical assessment of capacity.^12-14 Examples of assessment tools that may be utilized as a part of the assessment of capacity include: Mini Mental State Examination (MMSE); Montreal Cognitive Assessment (MoCA), the MacArthur Competence Assessment Tool for Treatment (MacCAT-T), Competency Interview Schedule, Structured Interview for Competency and Incompetency Assessment Testing and Ranking Inventory, Hopkins Competency Assessment (HCAT), the Mini-Cog, Aid to Capacity Evaluation, and the Capacity Assessment Tool (CAT).^15-18

Patient Management

The appropriate management of a patient who wishes to refuse medical care includes the following elements: determination of decision-making capacity, assessment of the reasons for refusal of care, delivery of information including risks and benefits of the proposed therapy, discharge planning, including the best treatment alternative, and documentation. Proper documentation of AMA is essential to documentation, and also can confer medicolegal protection.^19,20

Ensuring the safety of staff and other patients is an important concern when treating patients who may refuse medical care. Some patients may require physical or chemical restraints to assure safety of other patients or the treatment team. Physical restraints should be limited to use in cases where the safety of the patient, other patients, or staff is threatened, or to prevent elopement when the patient must be treated despite refusal. ACEP has stated in policy that, “restraints should be individualized and afford as much dignity to the patient as the situation allows” and “any restraints should be humanely and professionally administered.” The policy also states that protocols should ensure appropriate observation, treatment, assessments, and documentation of medical care.²¹

Case Discussion

In this case, assessment of decisional capacity is essential prior to the consideration of leaving AMA. It is reasonable to detain a patient who lacks decisional capacity until they regain decisional capacity or a safe disposition is determined. If there is any question regarding capacity, a standardized test, such as the MMSE, may be helpful. After the determination of appropriate decisional capacity, the physician should conduct an informed refusal discussion with the patient, including risks and benefits of the proposed tests and treatments, and risks of refusal. Alternatives to the recommended treatment should also be discussed and implemented when appropriate. Necessary follow-up care should be arranged, and the discussion and interactions should be documented.