14 - Decision-Making Capacity: Practical Tools for the Clinician

How do we determine whether a patient truly has the capacity to make their own medical decisions? In this episode of Key Perspectives, Eric Gordon, PA-C and Steve Arze, MD dive into one of the most common and ethically complex challenges in geriatrics, palliative care, and acute medicine: assessing medical decision-making capacity. The discussion focuses on three widely used, evidence-based frameworks and when each is most appropriate: Hopkins Competency Assessment Test (HCAT): A more comprehensive, structured evaluation often used for high-stakes, global competency questions such as financial decision-making, guardianship, and activation of durable power of attorney. Aid to Capacity Evaluation (ACE): A practical, bedside-ready tool for assessing capacity around a specific medical decision (e.g., surgery, chemotherapy, dialysis, or hospice), organized around key domains such as understanding, appreciation, reasoning, and voluntariness. CURVES Mnemonic: A rapid, clinically intuitive framework commonly used in emergency and acute care settings to assess a patient’s ability to choose, understand, reason, and communicate in time-sensitive situations. Through real-world examples, including refusal of hospitalization, major surgery, and end-of-life decisions, this episode explores how depression, psychosis, and situational distress can influence capacity assessments, and how clinicians can document these evaluations in a defensible, patient-centered way.