“The threshold of decision-making capacity required to refuse treatment increases in proportion to the risk and complexity of the decision.”
A patient who meets all four criteria at the time of evaluation should be allowed to leave AMA. A patient who lacks any of these components does not have the capacity to refuse care and should not be permitted to leave. For their safety, it may be necessary to involve hospital security or administer sedatives, if appropriate, to continue medical workup and treatment. This approach—standard across emergency medicine and other medical specialties—suggests that the same criteria should be used to assess both patients described above. Yet, many emergency physicians would feel differently about discharging these patients AMA, despite their similar age and presenting complaint. This contrast underscores a key but underemphasized concept in emergency medicine: the “sliding scale” of capacity, as described by medical ethicists. According to this framework, the threshold of decisionmaking capacity required to refuse (or accept) treatment increases in proportion to the risk of refusal and complexity of the decision. In the examples provided, the likelihood of a poor outcome after leaving the ED is vastly different for the two patients. For the patient experiencing a STEMI and bradycardia, the capacity threshold to refuse intervention is substantially higher than for the patient with benign chest pain. So how should emergency physicians apply the sliding scale in practice? We suggest three strategies: 1. C onsider risk and gather more information, when possible, to accurately assess it.
2. S pend more time evaluating capacity in cases involving higher medical risk or complex decisions. 3. C onsult a specialist for a second opinion when a patient’s capacity remains uncertain. Understanding the medical risk associated with leaving AMA is essential to evaluating capacity. Before allowing a patient to sign out AMA, clinicians should attempt to obtain additional context through further history-taking or a more thorough chart review. Although information is often limited, risk assessment amid uncertainty is a core skill in emergency medicine. Physicians should also devote more time to assessing the capacity of patients at higher medical risk or facing complex decisions. These patients must clearly possess all four elements of decision-making capacity and meet the heightened threshold dictated by the risk associated with the decision. While assessing capacity falls within the scope of emergency medicine and does not typically require psychiatric or ethics consultation, seeking a second opinion may be appropriate in uncertain or high-risk cases. For example, in Case 1, where the stakes are especially high, a specialist consultation can provide added clarity. Before consulting, however, physicians should make a final effort to ethically persuade the patient. This could involve active listening, offering small compromises (such as agreeing to one more test), or simply continuing to provide comfort and build rapport. If these efforts fail, a consultant may not only offer a fresh perspective but
also reinforce the seriousness of the situation to the patient. In some cases, the act of calling in a specialist—along with the wait involved—can prompt a patient to reconsider leaving. In the midst of a busy ED shift, one of the best outcomes is hearing a consultant say, “I’ve convinced them to stay for the workup and treatment.” As physicians, we are ethically bound both to respect a capacitated patient’s right to make an unsafe decision and to protect a noncapacitated patient from harm. Navigating this tension can be challenging in time-pressured, lifethreatening emergencies. Keeping the “sliding scale” framework in mind and applying these practical strategies can help emergency physicians make ethically sound decisions when patients seek to leave AMA.
ABOUT THE AUTHORS ana Barghout is a fourth-year R medical student at Weill Cornell Medicine pursuing a career in emergency medicine. Her research focuses on refusal of care, capacity assessment, and agitation management among older adults in emergency department settings. Josh Lachs is a research assistant in the Department of Emergency Medicine at Weill Cornell.
Dr. Rosen is an associate professor of emergency medicine at Weill Cornell Medicine and an emergency physician practicing at NewYorkPresbyterian Hospital
41