Capacity is a clinical judgement about one decision at one moment; competence is a court's word. An unwise decision is not incapacity, and a patient who nods at everything has not demonstrated anything. Interview a refusing patient against the four abilities, then build the room — agent, guardian, spouse, children — and see who legally decides and which of the three standards they must use.
Mr Okafor, 78, room 412Newly diagnosed colon cancer. The surgeon offered a hemicolectomy. He is refusing. His daughter is at the desk demanding a psychiatric evaluation “because he is clearly not competent.” Pick what he actually says to each of your four questions.
Screen the reversible contributors first
Build the roomMrs Doyle has lost capacity. Switch on who exists and who is present, and the bench will name the legal decision-maker and say why the others are not it.
Who is in the picture
Remember: never assume the person doing the most talking is the legal decision-maker, and learn your own state's default order — statutes differ.
Pick the case
Which standard must the surrogate use?
Strict order. Expressed wishes if known → substituted judgement → best interest only when the patient's values are genuinely unknowable.