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Capacity Assessment and Safe DispositionAPPROACH

TOXICOLOGY AND BEHAVIORAL · 19 SECTIONS

⚲

387 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Undifferentiated Overdose Opioid Toxicity Opioid Withdrawal Alcohol Intoxication Alcohol Withdrawal Stimulant Toxicity Pediatric Ingestion Carbon Monoxide Exposure Inhalational Or Chemical Exposure Suicidal Ideation And Self Harm Risk Assessment Acute Psychosis And Mania Symptoms Anxiety And Panic Symptoms Capacity Assessment And Safe Disposition Behavioral Escalation And Restraint Considerations

Pediatrics16▾

Environmental and Exposure4▾

01History/hx28

Capacity question and decision

›Decision specific capacity context

›Decision at hand

›Proposed options

›Time sensitivity

›Consequences of accepting

›Consequences of refusing

Baseline and trajectory

›Baseline cognitive and functional status

›Baseline orientation and memory

›Prior capacity concerns

›Prior similar presentations

›Baseline supports and supervision

Symptoms and precipitants

›Precipitants of possible incapacity

›Acute intoxication or withdrawal

›Delirium triggers

›Acute psychosis or mania symptoms

›Severe pain or distress

›Sleep deprivation

›Hypoglycemia risk

Communication and comprehension

›Communication factors affecting assessment

›Primary language

›Hearing or vision impairment

›Literacy and health literacy

›Aphasia or dysarthria

›Need for interpreter

02Alarm Features/alarm21

Immediate threats and instability

›Physiologic instability suggesting inability to safely decide

›Hypoxia

›Hypotension

›Severe tachycardia

›Fever with altered mental status

›Recurrent seizures

Neuro and cognitive red flags

›High risk neurologic features

›New focal neurologic deficit

›New confusion or fluctuating attention

›Reduced level of consciousness

›Severe headache with new mental status change

Behavioral safety red flags

›Safety risks requiring immediate containment

›Threats of violence

›Severe agitation with inability to redirect

›Inability to maintain basic self care

›Unsafe wandering or elopement risk

Legal and ethical escalation triggers

›High risk refusal scenarios

›Refusal of life saving therapy

›Refusal with evidence of delirium or intoxication

›Refusal with new psychosis symptoms

›Refusal with inability to state a stable choice

03Medications/meds23

Medication contributors to incapacity

›High risk medication classes

›Opioids

›Benzodiazepines

›Anticholinergics

›Sedative hypnotics

›Antipsychotics

›Polypharmacy

Recent medication changes

›Recent changes affecting cognition

›New medication starts

›Dose escalations

›Missed doses

›Withdrawal risk medications

Antidotes and reversal considerations

›Reversal options if clinically indicated and protocol aligned

›Naloxone for opioid toxicity

›Dextrose for hypoglycemia

›Thiamine before glucose when malnutrition risk

Agitation management examples

›Sedation options if safety risk and local protocol dependent

›Haloperidol IM 2 mg

›Haloperidol IM 5 mg

›Lorazepam IM 1 mg

›Lorazepam IM 2 mg

›Olanzapine IM 5 mg

›Olanzapine IM 10 mg

04Diet/diet12

Intake and metabolic risk

›Nutrition and hydration patterns

›Poor oral intake

›Dehydration risk

›Vomiting or diarrhea losses

Substance exposure through diet

›Exposures affecting cognition

›Caffeine excess

›Energy drink use

›Cannabis edibles

Alcohol exposure

›Alcohol use pattern when relevant

›Last drink timing

›Daily use pattern

›Withdrawal risk window

05Review of Systems/ros22

Neurologic and cognitive

›Neuro cognitive symptoms

›Confusion

›Inattention

›Memory impairment

›New headache

›Seizure activity

Psychiatric and behavioral

›Behavioral symptoms

›Hallucinations

›Delusions

›Disorganized thinking

›Severe anxiety or panic

›Agitation

Infectious and systemic

›Systemic symptoms

›Fever

›Chills

›Recent infection symptoms

›Weight loss

Cardiopulmonary contributors

›Cardiopulmonary symptoms

›Chest pain

›Dyspnea

›Palpitations

›Syncope

06Collateral History and Family History/chafh17

Collateral source and reliability

›Collateral information

›Source identity

›Relationship to patient

›Time with patient recently

›Reliability concerns

Baseline cognition and function collateral

›Baseline comparison

›Known dementia or neurocognitive disorder (F03.90)

›Developmental disorder history (F89)

›Baseline independence level

Family history relevant to capacity drivers

›Heritable conditions affecting cognition

›Early onset dementia family history

›Major psychiatric illness family history

›Seizure disorder family history (G40.909)

Social supports and supervision

›Support network

›Responsible adult availability

›Housing stability

›Caregiver capacity and willingness

07Risk Factors/rf21

Medical risks for delirium and impaired decision making

›Delirium risks

›Older age

›Known dementia (F03.90)

›Infection risk

›Polypharmacy

›Renal failure risk (N18.9)

Substance related risks

›Substance risks

›Alcohol use disorder (F10.20)

›Opioid use disorder (F11.20)

›Stimulant use disorder (F15.20)

›Sedative hypnotic use disorder (F13.20)

Situational risks for unsafe discharge

›Disposition risks

›Homelessness

›Lack of phone or transportation

›No safe place to stay

›No ability to obtain medications

Vulnerable populations

›Special populations

›Pregnancy

›Pediatrics and assent considerations

›Intellectual disability

›Language barriers without interpreter access

08Differential Diagnosis/ddx27

Life threatening

›Life threatening causes of impaired capacity

›Hypoxia (R09.02)

›Hypoglycemia (E16.2)

›Sepsis (A41.9)

›Intracranial hemorrhage (I62.9)

›Stroke (I63.9)

›Meningitis or encephalitis (G03.9)

›Toxidrome

›Severe alcohol withdrawal (F10.239)

Common

›Common causes of impaired decision making

›Delirium (R41.0)

›Intoxication

›Medication adverse effect

›Major depressive disorder with cognitive impairment (F32.9)

›Acute psychosis (F29)

›Mania or hypomania (F31.9)

Less common

›Less common causes

›Thyroid dysfunction (E03.9)

›Hepatic encephalopathy (K72.90)

›Uremic encephalopathy (N18.9)

›Nonconvulsive status epilepticus (G41.90)

›Wernicke encephalopathy (E51.2)

Mimics and pitfalls

›Mimics and interpretation traps

›Cultural disagreement misread as incapacity

09Past Medical History/pmh18

Neurocognitive and neurologic conditions

›Neuro history

›Dementia (F03.90)

›Prior stroke (I63.9)

›Seizure disorder (G40.909)

›Traumatic brain injury history (S06.9X0A)

Psychiatric history

›Mental health history

›Schizophrenia spectrum disorder (F20.9)

›Bipolar disorder (F31.9)

›Major depressive disorder (F32.9)

›Anxiety disorder (F41.9)

Substance use history

›Substance use disorders

›Alcohol use disorder (F10.20)

›Opioid use disorder (F11.20)

›Stimulant use disorder (F15.20)

Functional baseline and prior dispositions

›Prior baseline and prior episodes

›Baseline activities of daily living independence

›Prior involuntary holds or capacity findings

›Prior adverse outcomes after discharge

10Physical Exam/exam28

General and vital signs

›General appearance and physiologic status

›Level of consciousness

›Respiratory effort

›Signs of intoxication

›Signs of withdrawal

›Temperature pattern

Neurologic

›Neurologic exam

›Orientation

›Attention testing

›Speech and language

›Cranial nerves

›Motor and sensory asymmetry

›Gait if safe

Mental status and capacity elements

›Mental status exam aligned to capacity domains

›Understanding of information

›Appreciation of consequences

›Reasoning about options

›Ability to express a stable choice

Cardiopulmonary

›Heart and lung findings

›Hypoxia signs

›Arrhythmia clues

›Heart failure signs

Toxidrome and metabolic clues

›Targeted tox and metabolic exam

11Lab Studies/labs21

Core labs for reversible causes

›Screening labs when altered cognition suspected

›Glucose point of care

›Electrolytes including sodium

›Renal function

›Liver enzymes

›CBC

›TSH when clinically indicated

Toxicology testing

›Substance testing when results change management

›Blood ethanol

›Urine drug screen limitations

›Acetaminophen level with unclear ingestion history

›Salicylate level with concerning symptoms

Infection evaluation

›Infection workup when suspected

›Lactate

›Blood cultures before antibiotics when septic shock concern

›Urinalysis

›Viral testing local protocol dependent

Interpretation pitfalls

›Common lab pitfalls

›Normal labs do not exclude delirium

›Positive tox screen does not prove incapacity

›Negative tox screen does not exclude intoxication

12Imaging/img13

Scoring Systems

›Decision supports relevant to disposition and risk

›Delirium screening tools local protocol dependent

›Withdrawal severity scales local protocol dependent

›Capacity is clinical and decision specific

MRI

›MRI considerations for impaired cognition

›Indications focal neurologic deficit with non diagnostic CT

›Contraindications implanted ferromagnetic devices

›CT considerations for impaired cognition

›Noncontrast CT head for trauma or new focal deficit

›Radiation risk and pregnancy considerations

Ultrasound

›Ultrasound and POCUS

›Bladder scan for urinary retention delirium trigger

›Cardiac and lung POCUS for hypoxia or shock phenotype

13Special Tests/spec18

Bedside cognitive and delirium screening

›Brief bedside tools

›Attention testing

›Orientation testing

›Short term recall testing

›Delirium screening local protocol dependent

Capacity interview structure

›Capacity domains in structured interview

›Understanding teach back

›Appreciation of personal impact

›Reasoning comparison of options

›Choice consistency over time

Neurologic bedside maneuvers

›Focused bedside tests

›Finger to nose and heel to shin

›Pronator drift

›Romberg if safe

Substance withdrawal assessment

›Withdrawal assessment when suspected

›Tremor severity

›Autonomic hyperactivity signs

›Time since last use

14ECG/ecg13

Indications

›ECG indications in capacity affecting presentations

›Stimulant intoxication concerns

›Syncope or near syncope

›Chest pain or dyspnea

›Antipsychotic use with QT risk

High risk patterns

›ECG red flags

›Prolonged QTc

›Wide QRS

›Brugada pattern concern

›Ischemic changes

Serial ECG logic

›Serial ECG approach when clinically indicated

›Repeat with evolving symptoms

›Repeat after correction of electrolytes

15Assessment/ax20

Capacity determination framework

›Core capacity principles

›Decision specific

›Time specific

›Presumption of capacity unless evidence otherwise

›Supportive measures before concluding incapacity

Capacity domains synthesis

›Domain based conclusion

›Understanding adequate or inadequate

›Appreciation adequate or inadequate

›Reasoning adequate or inadequate

›Choice stable and communicable or not

Reversible causes and treatable drivers

›Potential reversible contributors

›Delirium (R41.0)

›Intoxication

›Hypoglycemia (E16.2)

›Hypoxia (R09.02)

›Infection (A41.9)

Risk and benefit weighting

›Threshold for capacity rigor increases with risk

›Low risk decisions

›High risk refusal

›High risk discharge decision

16Plan/plan29

Support decision making and re evaluate

›Measures to optimize capacity before final decision

›Treat pain

›Correct hypoxia

›Correct hypoglycemia

›Rehydrate if dehydrated

›Reduce environmental stimulation

›Interpreter use when needed

Differential Management

›!Alcohol intoxication→

Treat underlying medical drivers

›Medical stabilization priorities

›Sepsis pathway if suspected local protocol dependent

›Withdrawal treatment if indicated local protocol dependent

›Delirium bundle local protocol dependent

Safety and behavioral management

›Safety measures

›De escalation and least restrictive approach

›1 to 1 observation when needed

›Physical restraint local protocol dependent

›Chemical restraint local protocol dependent

Documentation essentials

›Documentation elements for defensible capacity determination

›Exact decision and alternatives explained

›Patient statements demonstrating understanding and reasoning

›Evidence of impairment

›Steps taken to optimize capacity

›Collateral input and reliability

17Disposition/dispo27

Discharge criteria

›Discharge acceptable when all criteria met

›Capacity for discharge decision present

›Medical stability

›No imminent safety risk

›Safe destination confirmed

›Reliable supervision when needed

›Ability to obtain food, shelter, and medications

Observation or admission criteria

›Higher level of care when criteria present

›Delirium with unsafe function (R41.0)

›Persistent intoxication impairing capacity

›Unstable vitals or hypoxia

›Need for serial exams or monitoring

›No safe discharge plan

Involuntary hold and substitute decision making

›Legal pathways local protocol dependent

›Emergency hold criteria

›Substitute decision maker identification

›Best interests standard when incapable

›Least restrictive alternative principle

Against medical advice pathway

›AMA discharge workflow when capacity present

›Specific risks of leaving reviewed

›Return precautions provided

›Harm reduction measures offered within scope

›Follow up arranged when possible

18Discharge Instructions/di20

Copy discharge instructions

›Plain language summary

›Today you were evaluated for your ability to make medical decisions and for medical causes that can affect thinking

›Your condition appears stable enough for you to leave based on the assessment today

›Safety and supervision

›Do not drive or operate machinery today

›Have a responsible adult stay with you for the next day if available

›Medications and substances

›Avoid alcohol and non prescribed substances

›Take prescribed medications only as directed

›Follow up

›Primary care follow up within 2 to 3 days

›Return earlier if symptoms worsen

›Return to emergency criteria

›New or worsening confusion

›Trouble breathing

›Chest pain

›Fainting

›New weakness or trouble speaking

›Fever with worsening mental status

›Feeling unsafe at home

19References/r9

Guidelines and core sources

›Capacity and consent references

›American Medical Association Code of Medical Ethics Informed consent and decision making capacity

›American College of Emergency Physicians Ethics Committee resources on refusal of treatment and capacity

›American Psychiatric Association resources on assessment of decision making capacity

›National Institute for Health and Care Excellence Delirium guideline 2023

›World Health Organization mhGAP Intervention Guide latest update local protocol dependent

›Project file reference

›Evidence based clinical reference generator instructions

›Formatting and structure constraints

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.

Capacity Assessment and Safe DispositionAPPROACH

TOXICOLOGY AND BEHAVIORAL · 19 SECTIONS

⚲

387 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx28

Capacity question and decision

›Decision specific capacity context

›Decision at hand

›Proposed options

›Time sensitivity

›Consequences of accepting

›Consequences of refusing

Baseline and trajectory

›Baseline cognitive and functional status

›Baseline orientation and memory

›Prior capacity concerns

›Prior similar presentations

›Baseline supports and supervision

Symptoms and precipitants

›Precipitants of possible incapacity

›Acute intoxication or withdrawal

›Delirium triggers

›Acute psychosis or mania symptoms

›Severe pain or distress

›Sleep deprivation

›Hypoglycemia risk

Communication and comprehension

›Communication factors affecting assessment

›Primary language

›Hearing or vision impairment

›Literacy and health literacy

›Aphasia or dysarthria

›Need for interpreter

02Alarm Features/alarm21

Immediate threats and instability

›Physiologic instability suggesting inability to safely decide

›Hypoxia

›Hypotension

›Severe tachycardia

›Fever with altered mental status

›Recurrent seizures

Neuro and cognitive red flags

›High risk neurologic features

›New focal neurologic deficit

›New confusion or fluctuating attention

›Reduced level of consciousness

›Severe headache with new mental status change

Behavioral safety red flags

›Safety risks requiring immediate containment

›Threats of violence

›Severe agitation with inability to redirect

›Inability to maintain basic self care

›Unsafe wandering or elopement risk

Legal and ethical escalation triggers

›High risk refusal scenarios

›Refusal of life saving therapy

›Refusal with evidence of delirium or intoxication

›Refusal with new psychosis symptoms

›Refusal with inability to state a stable choice

03Medications/meds23

Medication contributors to incapacity

›High risk medication classes

›Opioids

›Benzodiazepines

›Anticholinergics

›Sedative hypnotics

›Antipsychotics

›Polypharmacy

Recent medication changes

›Recent changes affecting cognition

›New medication starts

›Dose escalations

›Missed doses

›Withdrawal risk medications

Antidotes and reversal considerations

›Reversal options if clinically indicated and protocol aligned

›Naloxone for opioid toxicity

›Dextrose for hypoglycemia

›Thiamine before glucose when malnutrition risk

Agitation management examples

›Sedation options if safety risk and local protocol dependent

›Haloperidol IM 2 mg

›Haloperidol IM 5 mg

›Lorazepam IM 1 mg

›Lorazepam IM 2 mg

›Olanzapine IM 5 mg

›Olanzapine IM 10 mg

04Diet/diet12

Intake and metabolic risk

›Nutrition and hydration patterns

›Poor oral intake

›Dehydration risk

›Vomiting or diarrhea losses

Substance exposure through diet

›Exposures affecting cognition

›Caffeine excess

›Energy drink use

›Cannabis edibles

Alcohol exposure

›Alcohol use pattern when relevant

›Last drink timing

›Daily use pattern

›Withdrawal risk window

05Review of Systems/ros22

Neurologic and cognitive

›Neuro cognitive symptoms

›Confusion

›Inattention

›Memory impairment

›New headache

›Seizure activity

Psychiatric and behavioral

›Behavioral symptoms

›Hallucinations

›Delusions

›Disorganized thinking

›Severe anxiety or panic

›Agitation

Infectious and systemic

›Systemic symptoms

›Fever

›Chills

›Recent infection symptoms

›Weight loss

Cardiopulmonary contributors

›Cardiopulmonary symptoms

›Chest pain

›Dyspnea

›Palpitations

›Syncope

06Collateral History and Family History/chafh17

Collateral source and reliability

›Collateral information

›Source identity

›Relationship to patient

›Time with patient recently

›Reliability concerns

Baseline cognition and function collateral

›Baseline comparison

›Known dementia or neurocognitive disorder (F03.90)

›Developmental disorder history (F89)

›Baseline independence level

Family history relevant to capacity drivers

›Heritable conditions affecting cognition

›Early onset dementia family history

›Major psychiatric illness family history

›Seizure disorder family history (G40.909)

Social supports and supervision

›Support network

›Responsible adult availability

›Housing stability

›Caregiver capacity and willingness

07Risk Factors/rf21

Medical risks for delirium and impaired decision making

›Delirium risks

›Older age

›Known dementia (F03.90)

›Infection risk

›Polypharmacy

›Renal failure risk (N18.9)

Substance related risks

›Substance risks

›Alcohol use disorder (F10.20)

›Opioid use disorder (F11.20)

›Stimulant use disorder (F15.20)

›Sedative hypnotic use disorder (F13.20)

Situational risks for unsafe discharge

›Disposition risks

›Homelessness

›Lack of phone or transportation

›No safe place to stay

›No ability to obtain medications

Vulnerable populations

›Special populations

›Pregnancy

›Pediatrics and assent considerations

›Intellectual disability

›Language barriers without interpreter access

08Differential Diagnosis/ddx27

Life threatening

›Life threatening causes of impaired capacity

›Hypoxia (R09.02)

›Hypoglycemia (E16.2)

›Sepsis (A41.9)

›Intracranial hemorrhage (I62.9)

›Stroke (I63.9)

›Meningitis or encephalitis (G03.9)

›Toxidrome

›Severe alcohol withdrawal (F10.239)

Common

›Common causes of impaired decision making

›Delirium (R41.0)

›Intoxication

›Medication adverse effect

›Major depressive disorder with cognitive impairment (F32.9)

›Acute psychosis (F29)

›Mania or hypomania (F31.9)

Less common

›Less common causes

›Thyroid dysfunction (E03.9)

›Hepatic encephalopathy (K72.90)

›Uremic encephalopathy (N18.9)

›Nonconvulsive status epilepticus (G41.90)

›Wernicke encephalopathy (E51.2)

Mimics and pitfalls

›Mimics and interpretation traps

›Cultural disagreement misread as incapacity

09Past Medical History/pmh18

Neurocognitive and neurologic conditions

›Neuro history

›Dementia (F03.90)

›Prior stroke (I63.9)

›Seizure disorder (G40.909)

›Traumatic brain injury history (S06.9X0A)

Psychiatric history

›Mental health history

›Schizophrenia spectrum disorder (F20.9)

›Bipolar disorder (F31.9)

›Major depressive disorder (F32.9)

›Anxiety disorder (F41.9)

Substance use history

›Substance use disorders

›Alcohol use disorder (F10.20)

›Opioid use disorder (F11.20)

›Stimulant use disorder (F15.20)

Functional baseline and prior dispositions

›Prior baseline and prior episodes

›Baseline activities of daily living independence

›Prior involuntary holds or capacity findings

›Prior adverse outcomes after discharge

10Physical Exam/exam28

General and vital signs

›General appearance and physiologic status

›Level of consciousness

›Respiratory effort

›Signs of intoxication

›Signs of withdrawal

›Temperature pattern

Neurologic

›Neurologic exam

›Orientation

›Attention testing

›Speech and language

›Cranial nerves

›Motor and sensory asymmetry

›Gait if safe

Mental status and capacity elements

›Mental status exam aligned to capacity domains

›Understanding of information

›Appreciation of consequences

›Reasoning about options

›Ability to express a stable choice

Cardiopulmonary

›Heart and lung findings

›Hypoxia signs

›Arrhythmia clues

›Heart failure signs

Toxidrome and metabolic clues

›Targeted tox and metabolic exam

11Lab Studies/labs21

Core labs for reversible causes

›Screening labs when altered cognition suspected

›Glucose point of care

›Electrolytes including sodium

›Renal function

›Liver enzymes

›CBC

›TSH when clinically indicated

Toxicology testing

›Substance testing when results change management

›Blood ethanol

›Urine drug screen limitations

›Acetaminophen level with unclear ingestion history

›Salicylate level with concerning symptoms

Infection evaluation

›Infection workup when suspected

›Lactate

›Blood cultures before antibiotics when septic shock concern

›Urinalysis

›Viral testing local protocol dependent

Interpretation pitfalls

›Common lab pitfalls

›Normal labs do not exclude delirium

›Positive tox screen does not prove incapacity

›Negative tox screen does not exclude intoxication

12Imaging/img13

Scoring Systems

›Decision supports relevant to disposition and risk

›Delirium screening tools local protocol dependent

›Withdrawal severity scales local protocol dependent

›Capacity is clinical and decision specific

MRI

›MRI considerations for impaired cognition

›Indications focal neurologic deficit with non diagnostic CT

›Contraindications implanted ferromagnetic devices

›CT considerations for impaired cognition

›Noncontrast CT head for trauma or new focal deficit

›Radiation risk and pregnancy considerations

Ultrasound

›Ultrasound and POCUS

›Bladder scan for urinary retention delirium trigger

›Cardiac and lung POCUS for hypoxia or shock phenotype

13Special Tests/spec18

Bedside cognitive and delirium screening

›Brief bedside tools

›Attention testing

›Orientation testing

›Short term recall testing

›Delirium screening local protocol dependent

Capacity interview structure

›Capacity domains in structured interview

›Understanding teach back

›Appreciation of personal impact

›Reasoning comparison of options

›Choice consistency over time

Neurologic bedside maneuvers

›Focused bedside tests

›Finger to nose and heel to shin

›Pronator drift

›Romberg if safe

Substance withdrawal assessment

›Withdrawal assessment when suspected

›Tremor severity

›Autonomic hyperactivity signs

›Time since last use

14ECG/ecg13

Indications

›ECG indications in capacity affecting presentations

›Stimulant intoxication concerns

›Syncope or near syncope

›Chest pain or dyspnea

›Antipsychotic use with QT risk

High risk patterns

›ECG red flags

›Prolonged QTc

›Wide QRS

›Brugada pattern concern

›Ischemic changes

Serial ECG logic

›Serial ECG approach when clinically indicated

›Repeat with evolving symptoms

›Repeat after correction of electrolytes

15Assessment/ax20

Capacity determination framework

›Core capacity principles

›Decision specific

›Time specific

›Presumption of capacity unless evidence otherwise

›Supportive measures before concluding incapacity

Capacity domains synthesis

›Domain based conclusion

›Understanding adequate or inadequate

›Appreciation adequate or inadequate

›Reasoning adequate or inadequate

›Choice stable and communicable or not

Reversible causes and treatable drivers

›Potential reversible contributors

›Delirium (R41.0)

›Intoxication

›Hypoglycemia (E16.2)

›Hypoxia (R09.02)

›Infection (A41.9)

Risk and benefit weighting

›Threshold for capacity rigor increases with risk

›Low risk decisions

›High risk refusal

›High risk discharge decision

16Plan/plan29

Support decision making and re evaluate

›Measures to optimize capacity before final decision

›Treat pain

›Correct hypoxia

›Correct hypoglycemia

›Rehydrate if dehydrated

›Reduce environmental stimulation

›Interpreter use when needed

Differential Management

›!Alcohol intoxication→

Treat underlying medical drivers

›Medical stabilization priorities

›Sepsis pathway if suspected local protocol dependent

›Withdrawal treatment if indicated local protocol dependent

›Delirium bundle local protocol dependent

Safety and behavioral management

›Safety measures

›De escalation and least restrictive approach

›1 to 1 observation when needed

›Physical restraint local protocol dependent

›Chemical restraint local protocol dependent

Documentation essentials

›Documentation elements for defensible capacity determination

›Exact decision and alternatives explained

›Patient statements demonstrating understanding and reasoning

›Evidence of impairment

›Steps taken to optimize capacity

›Collateral input and reliability

17Disposition/dispo27

Discharge criteria

›Discharge acceptable when all criteria met

›Capacity for discharge decision present

›Medical stability

›No imminent safety risk

›Safe destination confirmed

›Reliable supervision when needed

›Ability to obtain food, shelter, and medications

Observation or admission criteria

›Higher level of care when criteria present

›Delirium with unsafe function (R41.0)

›Persistent intoxication impairing capacity

›Unstable vitals or hypoxia

›Need for serial exams or monitoring

›No safe discharge plan

Involuntary hold and substitute decision making

›Legal pathways local protocol dependent

›Emergency hold criteria

›Substitute decision maker identification

›Best interests standard when incapable

›Least restrictive alternative principle

Against medical advice pathway

›AMA discharge workflow when capacity present

›Specific risks of leaving reviewed

›Return precautions provided

›Harm reduction measures offered within scope

›Follow up arranged when possible

18Discharge Instructions/di20

Copy discharge instructions

›Plain language summary

›Today you were evaluated for your ability to make medical decisions and for medical causes that can affect thinking

›Your condition appears stable enough for you to leave based on the assessment today

›Safety and supervision

›Do not drive or operate machinery today

›Have a responsible adult stay with you for the next day if available

›Medications and substances

›Avoid alcohol and non prescribed substances

›Take prescribed medications only as directed

›Follow up

›Primary care follow up within 2 to 3 days

›Return earlier if symptoms worsen

›Return to emergency criteria

›New or worsening confusion

›Trouble breathing

›Chest pain

›Fainting

›New weakness or trouble speaking

›Fever with worsening mental status

›Feeling unsafe at home

19References/r9

Guidelines and core sources

›Capacity and consent references

›American Medical Association Code of Medical Ethics Informed consent and decision making capacity

›American College of Emergency Physicians Ethics Committee resources on refusal of treatment and capacity

›American Psychiatric Association resources on assessment of decision making capacity

›National Institute for Health and Care Excellence Delirium guideline 2023

›World Health Organization mhGAP Intervention Guide latest update local protocol dependent

›Project file reference

›Evidence based clinical reference generator instructions

›Formatting and structure constraints

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.