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Capacity assessment — ABIM Board MCQ

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ModerateGeneral Internal MedicineCapacity assessmentABIM Board

A 79-year-old woman with mild dementia is advised to be hospitalized for pneumonia but refuses admission. After the physician explains her diagnosis, the proposed treatment, reasonable alternatives, and the risks of refusing hospitalization, she accurately describes this information in her own words. She acknowledges that refusal could lead to respiratory failure or death, compares the available options, and consistently explains that remaining at home accords with her longstanding values. She has no delirium, psychosis, or intoxication. Which of the following is the most appropriate management?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: E — Honor the refusal, document informed refusal, and arrange feasible outpatient care

Explanation lettering: D = shown as A · C = shown as B · E = shown as C · A = shown as D · B = shown as E

The correct answer is B. Decision-making capacity is functional and decision-specific; dementia alone does not establish incapacity. This patient can understand the relevant information, appreciate how the consequences apply to her, reason among the alternatives, and communicate a stable choice. A capable adult may refuse recommended treatment even when refusal creates a substantial risk of death. The physician should document the capacity assessment and informed refusal and offer the safest feasible alternative plan. Her son cannot replace her as decision-maker while she retains capacity (C). Neither the diagnosis of dementia nor disagreement with the physician justifies overriding her choice (A), restraint (D), or guardianship proceedings (E). Surrogate or judicial decision-making becomes relevant only if she lacks capacity.

Reference: Centers for Medicare & Medicaid Services. Medicare and Medicaid Programs; Hospital Conditions of Participation: Patients' Rights, 42 CFR §482.13(b)(2), 2006. https://www.cms.gov/medicare/provider-enrollment-and-certification/certificationandcomplianc/downloads/patientsrights.pdf