Capacity vs Competence
Capacity is clinical / physician-assessed; Competence is legal / judge-decided
Tarasoff Duty
Mandatory duty to warn/protect when specific identifiable third party is threatened
Minors Consent
Minors can consent for STIs, contraception, prenatal care, substance abuse
Malpractice 4 Ds
Duty, Dereliction (breach), Direct cause, Damages
Decision-Making Capacity & Informed Consent
Every adult patient is presumed to possess decision-making capacity unless proven otherwise. Capacity is situational and decision-specific:
The 4 Components of Clinical Capacity (CURVE)
1. Communication: Patient can clearly articulate their choice.
2. Understanding: Patient grasps the medical condition and options.
3. Reasoning: Patient can weigh benefits, risks, and burdens rationally.
4. Appreciation: Patient understands how this applies to their own life.
2. Understanding: Patient grasps the medical condition and options.
3. Reasoning: Patient can weigh benefits, risks, and burdens rationally.
4. Appreciation: Patient understands how this applies to their own life.
Exceptions to Informed Consent (W-BICE)
1. Emergency / Implied consent: Immediate life/limb threat when patient is incapacitated.
2. Waiver: Patient explicitly waives their right to decide.
3. Therapeutic privilege: Extreme, rare exception where disclosure would cause immediate severe harm.
2. Waiver: Patient explicitly waives their right to decide.
3. Therapeutic privilege: Extreme, rare exception where disclosure would cause immediate severe harm.
Minor Consent Exceptions
Parents provide consent for minors except in: Emancipated minors (married, military, self-supporting/living independently, high school graduate) and confidential care areas (sexually transmitted infections, pregnancy/prenatal care, contraception, substance abuse treatment).
Confidentiality & Mandatory Reporting Duties
Physician-patient confidentiality is protected under HIPAA, but state and federal law mandates breach of confidentiality in specific scenarios:
| Scenario / Condition | Legal Duty | Core Action Required |
|---|---|---|
| Tarasoff Ruling (Duty to Protect) | Mandatory breach | Warn law enforcement and notify the identifiable victim |
| Suspected Child Abuse or Neglect | Mandatory report immediately | Contact Child Protective Services (CPS) / law enforcement; patient/parent consent NOT required |
| Suspected Elder Abuse or Neglect | Mandatory report | Contact Adult Protective Services (APS) |
| Domestic Violence (Intimate Partner) | NOT mandatory in most states | Offer support, social work, emergency shelter; do NOT report against adult patient's will |
| Reportable Infectious Diseases | Mandatory public health report | Report gonorrhea, chlamydia, syphilis, HIV, TB, measles, hepatitis to health dept |
| Impaired Healthcare Colleague | Mandatory report | Report to hospital physician health committee / licensing board |
End-of-Life Care, Surrogacy & Advance Directives
Autonomy persists even after a patient loses capacity through advance planning:
Hierarchy of Surrogates
1. Designated Durable Power of Attorney for Healthcare (DPOA / Healthcare Proxy)
2. Legal guardian
3. Spouse
4. Adult children
5. Parents
6. Adult siblings.
2. Legal guardian
3. Spouse
4. Adult children
5. Parents
6. Adult siblings.
Substituted Judgment vs Best Interests
Surrogates must first apply Substituted Judgment (what would the patient have chosen based on known values?). If patient values are completely unknown, apply Best Interests Standard.
Brain Death Criteria
Irreversible cessation of all brain functions including brainstem: coma, absence of brainstem reflexes (pupils fixed, no corneal, no oculocephalic/vestibular, no gag), and positive apnea test (pCO2 >= 60 mmHg without spontaneous respiration). Once confirmed, family consent is NOT required to remove ventilator.
COMLEX / OMM Integration
NBOME High-Yield Correlate
Informed Consent Specifics in Osteopathic Manipulation
- Informed Consent for OMT: Prior to performing any OMT technique (especially high-velocity low-amplitude thrust), the physician must discuss indications, potential side effects (soreness for 24–48 hours, stiffness), rare risks (stroke/dissection in cervical spine), and alternatives.
- Right of Refusal: The patient retains absolute autonomy to decline manual therapy at any moment, even if previously consented.
- Right of Refusal: The patient retains absolute autonomy to decline manual therapy at any moment, even if previously consented.
Board Traps & Common Distractors
- Trap: Calling the police for domestic violence against an adult victim's wishes. This can endanger the patient. Offer resources and safety planning instead.
- Trap: Confusing a living will with a medical power of attorney. A living will specifies interventions (ventilator, tube feeding); DPOA designates a person to make decisions.
- Trap: Allowing parents to refuse life-saving treatment for a child based on religious beliefs (e.g. blood transfusion in pediatric trauma). Always petition for court custody / administer emergent blood.