BC-focused clinical support

Capacity to Refuse

A practical framework for assessing decision-specific capacity, supporting informed choice and documenting refusals.

Quick card

Start with three principles

Decision- and time-specific

Capacity is assessed for this decision, at this time. It may change as the patient or circumstances change.

Disagreement is not incapacity

An adult may make a choice clinicians consider unwise if they can understand and appreciate the relevant information.

Treat reversible impairment

Address reversible factors and reassess. Intoxication, dementia, mental illness, disability or age alone does not decide capacity.

Assessment framework

Understand · Appreciate · Reason · Communicate · Voluntary

U

Understand

Can the patient explain the condition, proposed care and alternatives in their own words?

A

Appreciate

Can the patient explain how the likely benefits and risks apply to their own situation?

R

Reason

Can the patient compare options and give a coherent reason for the choice?

C

Communicate

Can the patient communicate a stable choice by speech, writing, gesture or supported communication?

V

Voluntary

Is the decision free from coercion or undue influence?

Reversible factors

Look for impairment you can address

  • Hypoxia or hypercapnia
  • Hypoglycemia or another metabolic disturbance
  • Hypotension or shock
  • Head injury, stroke, seizure or postictal state
  • Intoxication, poisoning or medication effect
  • Delirium, infection or abnormal temperature
  • Severe pain, anxiety or communication barrier
  • Fatigue, sleep deprivation or acute psychiatric symptoms
High-risk refusals

Escalate and consult

  • Chest pain, suspected ACS or abnormal ECG
  • Stroke/TIA symptoms, seizure or altered mental status
  • Respiratory distress, hypoxemia or anaphylaxis
  • Major trauma, head injury or anticoagulant-associated injury
  • Sepsis, shock, severe bleeding or obstetric emergency
  • Poisoning, intoxication, suicidal risk or fluctuating cognition
  • Any patient in police custody or other locally designated vulnerable situation
Practical resources

Assess, teach back and document

Teach-back questions

Prompts that test understanding and appreciation without relying on orientation alone.

Documentation template

A structured refusal record and complete resolved-chest-pain SOAP example.

Minors and substitute decisions

Know when the pathway changes

BC consent rules for minors, mature minors, representatives, advance directives and substitute decision makers are context-specific. Follow current law and employer policy, involve the appropriate decision maker, and consult CliniCall/medical oversight for uncertainty or high-risk refusal. Never infer capacity or incapacity from age or diagnosis alone.