Review of the medical literature using Pub-Med may also provide guidance. A literature search using the term “decisional capacity in the emergency department” found an article published in 2017 by members of the ACEP Ethics Committee, entitled “Refusal of Emergency Medical Treatment: Case Studies and Ethical Foundations.”⁴ The article states:

Decisional capacity (decisionmaking capacity) is essential to patients’ autonomous medical decisionmaking. The assessment of decisional capacity is an essential skill for emergency physicians. The burden of proof is on the physician to determine whether the patient possesses appropriate decisional capacity. Patients who do not possess it should not be allowed to refuse necessary medical treatment until decisional capacity is restored. There may be significant variation in providers’ assessment of decisional capacity, which underscores the need for a better understanding of decisional capacity and its assessment in the ED environment. Capacity is composed of four essential elements: understanding, appreciation, reasoning, and expression of choice. Thus, an individual must be able to understand the information delivered, appreciate how to apply it to his or her own situation, reason to make an appropriate decision, and communicate that choice.

Case Summary

Assessment of decisional capacity is essential. Decisional capacity is dynamic and may vary over time, as the patient’s mental status or clinical or environmental factors may change. In cases where decisional capacity is unclear, standardized tests may be valuable in the determination of capacity. One standardized test which is easily administered in emergency medicine is the Mini-Mental Status Examination (MMSE).⁵ Low scores on the MMSE might indicate a patient might lack capacity but normal scores do not assure capacity is present. Decisional capacity may be impaired by numerous conditions, including dementia, intoxication, psychiatric conditions, language impairment, cultural issues, physical communication impairments, severe pain, organic disease states and numerous other conditions.⁶

Decisional capacity is frequently impaired in cases of impaired consciousness, intoxication with alcohol, drugs, or toxins, severe pain, impaired cognition or any condition rendering a patient unable to participate in medical decision making. In these circumstances, and when no one legally authorized to act on the patient’s behalf is immediately available, physicians should act in the patient’s best interest according to what a “reasonable person” would want in similar circumstances. If the patient is unable or unwilling to cooperate with assessment of decisional capacity, he should be detained until assessment can safely be completed to allow respect for patient autonomy when the patient is fully capable of medical decision making.