'Capacity' is a word that will inevitably be thrown around by us hundreds - if not thousands - of times throughout our careers as emergency medicine physicians. Whether it be a patient with major depressive disorder who is declining life-saving treatment for a pulmonary embolism, or an elderly woman brought in by her home health aid because of chest pain who is now refusing a basic EKG and labs, the task falls on us to deeply consider healthcare law and ethics in reaching a decision over whether our patients hold the capacity to make their own healthcare decisions.

While working an overnight shift on my New York Presbyterian emergency medicine sub-internship, I found my team presented with the dilemma of questioning a patient's capacity. However, when I offered to conduct a formal capacity assessment with the patient, my attending remarked, "just page psych; we're a real hospital."

Increased attention to the concept of capacity over the past few decades has led to a noticeable rise in the number of referrals for psychiatric evaluation of mental capacity in relation to patients' consent to treatment. What is important to note, however, is that any licensed physician - not just a psychiatrist - is capable of making a determination of incapacity. The task ultimately boils down to training physicians to confidently employ valid, reliable, and clinically useful tools for assessing and documenting incapacity in their own patients.

As clinicians, we must carefully balance the principles of autonomy (self-determination) and beneficence (protection) for each of the patients that enter our emergency department. Capacity comes into play here by formally stating whether a patient has the legal right to consent to or refuse potentially life-saving interventions. And because a designation of 'incapacity' can be a vehicle for the swift removal of an individual's fundamental rights, it is imperative that every clinician - not just our on-call psychiatrists - are well-equipped with the knowledge and tools necessary to guide the outcomes of these difficult scenarios.

Okay, so hopefully by now you recognize that having the ability to assess capacity is important, no matter what kind of doctor you are. But is it really necessary to be rigorously trained in conducting and interpreting an assessment? In one study conducted back in 1997, five physicians were asked to review videotapes of a capacity assessment and rate the patient's level of capacity. Turns out, the physicians achieved a rate of agreement that was no better than chance.

The term "gestalt" gets tossed around a lot in #FOAMed. At first, I had no idea what it meant; when I looked it up in a dictionary, I got the following definition: "a structure, configuration, or pattern of physical, biological, or psychological phenomena so integrated as to constitute a functional unit with properties not derivable by summation of its parts." So basically, the definition just left me more confused about what everyone was talking about.

But then I came across this blog post written by St. Emlyn's 'Meducation in Vechester,' which offered an interesting commentary on the term. I can't do it full justice in the span of this presentation, so do yourself a favor and check out the post here:

http://stemlynsblog.org/gestalt-st-emlyns/

But in summary, gestalt is this ability to make some sort of sensory interpretation that is greater than the sum of it's parts. It's that nagging feeling in the back of your head that, without any fully sound explanation, you know that something about the patient in A6 texting her BFF Jill is just... off.

So why do I bring up gestalt? Well, although the detection of incapacity depends largely in part on an appropriate level of suspicion by physicians, their 'gestalt,' they can be more certain of this gut feeling by familiarizing themselves with the applicable criteria of capacity and the use of a systematic approach in its assessment.

Basically, consider this deck to be a strong supplement to your trusty ol' gestalt.

Worry not, grasshopper.

The key to conducting a sound capacity assessment is to recall these four domains:

1. Communicate
2. Understand
3. Appreciate
4. Reason

Just use the brilliant acronym CUAR to remember these. I realize "cuar" isn't a real word, but neither is NEXUS or PERC and we have no trouble remembering what they're all about.

(Note: I consulted Google and actually 'nexus' is a real word; you learn something new every day. But my point still stands. CUAR for capacity.)

Let's go through each of these domains in a little more detail.

Your task here is simple. Can your patient indicate an actual treatment choice (or lack thereof)? All this requires of you is asking, "can you tell me what your decision is?" If they're indifferent, follow up with, "what is making it hard for you to decide?"

Red flags in the 'communicate' domain typically come in the form of frequent reversals in clinical decisions by the patient.

The challenge presented to the patient here is to have them demonstrate that they grasp the fundamental meaning of information communicated by you. Your job at this point is to encourage the patient to paraphrase the disclosed information about their medical condition and the treatment options available to them. There's a bunch of ways to ask these questions, but here's my CliffsNotes summary:

"Tell me in your own words, what I have told you about...
- the problem with your health now?"
- the recommended treatment for this?"
- the potential benefits and risks of this treatment?"
- the risks and benefits of no treatment?"

'Appreciate' is kind of similar to 'understand' in that the patient is asked to elaborate on their condition, the treatment options, their benefits and risks, as well as the alternatives. What makes it different from the 'understand' domain is that it asks the patient to present THEIR views on these subjects instead of summarizing yours. What this looks like is as follows:

"What do you believe is wrong with your health?"
"Do you believe that you need any treatment?"
"What is treatment likely to do for you?"
"What makes you believe it will have that effect?"
"What do you believe will happen if you are not treated?"
"Why do you think I recommended treatment?"

Red flags in this domain include patients failing to acknowledge that they have a medical condition (what our psychiatry friends call "lack of insight"), or the demonstration of delusions or pathological distortion/denial.

Finally, you need to have your patient engage in a process of rational manipulation of the presented information. Basically, you are asking them to compare treatment options and consequences, and offer their reasons behind selecting a certain option. Here, we can ask questions such as:

"How did you decide to accept or reject the recommended treatment?"
"What makes your chosen option better than the alternative option?"

This final domain of 'reason' essentially focuses on the process by which your patient reached their decision, NOT the outcome of the patient's choice. Remember that in honoring the principle of autonomy, a patient with full capacity has the right to make "unreasonable" decisions.

So, the next time you start questioning your patient's capacity to decline treatment, try to spare your colleagues a trip down to the ED to figure it out for you; you've got this. By simply being aware of the relevant domains and using a structured approach to a capacity assessment, you should feel confident in reaching a decision.

Don't believe me? In one set of studies, simply providing physicians with specific legal standards to guide their judgments (similar to the domains outlined in this deck) significantly increased inter-rater agreement (the kappa statistic for agreement increased from 0.14 in that previously-mentioned 1997 study to a respectable 0.46). Another study found that asking physicians and nurses to use a systematic set of questions for capacity assessment led to a high rate of agreement with expert judgments. So really, guys; this approach works.

As the patient's primary provider in the emergency department, you have home field advantage of familiarity with the patient and the treatment options available to them. Although psychiatrists have specific expertise in diagnosing and treating many of the disorders that cause incapacity, for many routine cases, decision-making capacity is best assessed by the clinician responsible for the patient's care (that's you).

But does that mean you should never request a psych consult for a formal capacity assessment?

Well, you would think that by now, we would have come up with a simple instrument to screen patients for impaired capacity that would facilitate the identification of patients who may require more detailed assessment; unfortunately, to date the quest for a brief neuropsychological screening instrument has not yielded consistent findings. So use your best judgement to decide when an assessment may be beyond your training (such as when mental illness is present), and go ahead and request that psychiatric consultation.

Keep in mind, however, that whether a mental health consultant renders an opinion about capacity, the final responsibility for determining capacity rests with you, as the treating clinician. If you find yourself struggling to reach an agreement with the consulting physician about your patient's decision-making capacity, it may be necessary to take things a step further and consult the ethics service.

And now, the list of references...

Appelbaum, Paul S. "Assessment of patients' competence to consent to treatment." New England Journal of Medicine 357.18 (2007): 1834-1840.

Ganzini, Linda, et al. "Ten myths about decision-making capacity." Journal of the American Medical Directors Association 5.4 (2004): 263-267.

Lamont, Scott, Yun‐Hee Jeon, and Mary Chiarella. "Assessing patient capacity to consent to treatment: An integrative review of instruments and tools." Journal of clinical nursing 22.17-18 (2013): 2387-2403.