Risk management for the emergency physician: competency and decision-making capacity, informed consent, and refusal of care against medical advice.

This article focuses on those times that the emergency physician (EP) and patient do not agree on a treatment option. Attention is placed on the risk management issues relevant to the patient's unexpected choice. Emphasis is placed on determining a patient's competency or capability of making clinical decisions, with particular focus on the EP deciding that patient competency requires a formal evaluation. The EP should have a strategy for assessing clinical decision-making capability and an understanding of what circumstances should act as a trigger for considering such an assessment. Attention to documentation issues around informed consent, common barriers to consent, refusal of care, and ED discharge against medical advice are examined.