Capacity Assessment

AMA documentation should mirror the informed declination form and include:
o The patient has decided to leave AMA because they state:
o The patient has been assessed to have the capacity to make decisions by the following:
§ An example of what would be appropriate to include in this section of
documentation: “The patient is clinically sober, free from distracting injury,
appears to have intact insight, judgment and reason and in my opinion has the
capacity to make decisions.”
o The patient and the provider agree on the following symptoms and the patient
understands the provider’s assessment, diagnoses and concerns.
o The risks have been explained to the patient:
o The benefits of remaining in the environment /admitting to the hospital have been
explained:
o Alternatives to leaving AMA have been explored and explained:
§ The patient understood risks and benefits and did so by ____. The patient had
an opportunity to ask questions about their medical condition and the
significance or consequences of leaving AMA. This was witnessed by ____ and
author of documentation
o The patient was provided: prescriptions, follow up appointments, discharge instructions

This patient has elected to leave against medical advice. In my opinion, the patient has capacity to leave AMA. The patient is clinically sober, free from distracting injury, appears to have intact insight and judgment and reason, and in my opinion has capacity to make decisions. I explained to the patient that his symptoms may represent *** and the patient verbalized understanding of my concerns.

I had a discussion with the patient about their workup and results, and that they may still have *** despite ***. I informed the patient that the next step in diagnosis and treatment would be ***, and they verbalized understanding of this as well. I explained the risks of leaving without further workup or treatment, which included reasonably foreseeable complications such as death, serious injury, permanent disability, and ***. I also offered alternatives to departing AMA such as assigning the patient a different provider or an alternate workup pathway.

The patient is refusing any further care, specifically ***, and is leaving against medical advice. I am unable to convince the patient to stay. I have asked them to return as soon as possible to complete their evaluation, and also explained that they were welcome to return to the ER for further evaluation whenever they choose. I have asked the patient to follow up with their primary doctor as soon as possible. I have answered all their questions. Patient signed***did not sign AMA paperwork.

Antipsychotics	Consent was obtained to start the antipsychotic. The benefits of treatment were discussed, including reduction of psychotic symptoms, improved insight, judgment, and reduction in maladaptive behaviours. We also discussed the likely possibility of worsening symptoms and the clinical course without treatment. The rare risk of death/CVA, NMS, parkinsonism, involuntary movements due to EPS were also discussed. We discussed possible side effects including falls, sedation, metabolic syndrome, and QTc prolongation/arrhythmia. We also discussed the importance of ongoing monitoring for metabolic syndrome and side effects such as hyperlipidemia, and elevated glucose.

Antidepressants	Consent was obtained to start an antidepressant for the patient. We discussed the common side effects, including nausea, headaches, sexual dysfunction, and increased anxiety, and that most of these side effects will self-resolve 1 to 2 weeks into treatment. Rare but serious side effects, including serotonin syndrome, hyponatremia, elevated bleeding risk, anti-depressant-induced mania/hypomania, and increased risk of suicidal ideation were also discussed.

he key components of obtaining informed consent from your patient includes discussing the following:

Nature of the treatment
Expected benefits of the treatment
Material risks of the treatment
Material side effects of the treatment
Alternative courses of action (i.e - alternate treatments including non-pharmacological)
Likely consequences of not having the treatment
Likely consequences of having the treatment

What Are 'Material' Risks and Side Effects?
Material risks or side effects of treatment include:
Those which are probable or likely to occur
Those which are possible if they carry serious consequences
Those which a reasonable person in the patient’s specific circumstances would want to know in order to make a decision to give or refuse consent

Understanding: 

Description
Is the person is able to understand the information that is relevant to making a decision about the treatment? Do they have the cognitive ability to attend to, comprehend, retain and process relevant information?	

Factors	
What information has been given to the patient?
What is the patient's response to this information?

Examples of failing this branch	
Individuals with a cognitive condition (e.g. - dementia, traumatic brain injury) that impedes their ability to retain and or process the information.
Delirium and decreased level of consciousness leading to inability to understand and appreciate that treatment is needed

There is a very high threshold to actually fail this branch of the test (and most patients will pass it)

Appreciation: 
Description
Are they able to appreciate the reasonably foreseeable consequences of a decision or lack of decision. An individual fails this test if they are unable to recognize the possibility that they are affected by the manifestations of the condition you describe to them and cannot appreciate the consequences of the decision being made.

Factors	
Discuss what you think are the reasonably forseeable consequences from treatment, or lack of treatment.
Are they able to apply the relevant information to their own circumstances and to weigh foreseeable risks and benefits?

Examples of failing this branch	
Delusions and hallucinations leading to inability to appreciate that treatment is needed

A patient diagnosed with schizophrenia is able to understand the information about the illness, and that it can affect some people, but does not believe that he/she has that illness, in spite of a two-year history of symptoms consistent with schizophrenia, hospitalization and treatment.

A patient diagnosed with anorexia nervosa is able to understand and intelligently discuss the nature and consequences of the illness and readily acknowledges that people have to eat or that they may die. In spite of this, the patient is not able to eat and maintains that he/she will be fine.