Emergency Department Operations, EMTALA & Medicolegal Principles

* Competency vs. Capacity: Competency is a legal status determined exclusively by a judge in a court of law. Capacity is a clinical determination made by any licensed physician at the bedside for a specific decision at a specific point in time. * The Four Functional Criteria for Decision-Making Capacity: 1. Understanding: The patient can restate in their own words the diagnosis, proposed treatment, alternatives, and risks. 2. Appreciation: The patient acknowledges that they have this condition and that the consequences of treatment or non-treatment apply to their own life. 3. Reasoning: The patient demonstrates logical thought processes in arriving at their decision, even if the clinician disagrees with their values. 4. Expressing a Choice: The patient communicates a clear, stable, and consistent choice without vacillating erratically.

• Assuming intoxication automatically eliminates capacity: An intoxicated patient (even with an elevated blood alcohol level) can possess decision-making capacity if they meet the four functional criteria; conversely, a sober patient with delirium may lack capacity.
• Refusing to give discharge medications or prescriptions to an AMA patient: Withholding care, prescriptions, or discharge instructions out of spite when a patient signs AMA constitutes abandonment and malpractice; always provide harm reduction and safe return precautions.