Ethics, Legal, and Systems of Care
Core concepts
Understand informed consent and decision-making capacity - capacity is task-specific, not global; assess understanding, appreciation, reasoning, and choice. Know surrogate decision-making hierarchies and advance directives. Understand brain death determination (coma, absent brainstem reflexes, apnea) and that it differs from disorders of consciousness. Know the legal landscape: disability determination, workers' compensation, return-to-work accommodations, and mandated reporting of suspected abuse. Understand systems of care: trauma centers, rehabilitation levels (inpatient, outpatient, community), and care coordination. Recognize health disparities and access barriers.
Traps
Questions test whether you equate capacity with competence - competence is a legal determination; capacity is clinical and decision-specific. Do not conflate brain death with persistent vegetative state (brain death has no brainstem function and no respiration). Remember that a patient who refuses treatment may still have capacity. Avoid assuming family always overrides patient wishes when an advance directive exists.
Rule of thumb
"Capacity is decision-specific": a patient may have capacity for one choice and not another. Always seek the least restrictive, patient-centered option.
Worked example
A patient with TBI refuses a recommended procedure but can explain risks, alternatives, and consequences. This demonstrates decision-making capacity; refusal should be respected even if the team disagrees.