19.1 Ethical and Legal Evaluation Issues

The current FNP-BC Test Content Outline scores Domain V Evaluation at 23 items / 15% through October 18, 2026, and 20 items / 13% beginning October 30, 2026. Official knowledge includes ethical and legal principles; the outline names justice, consent, guardianship, and bioethics. Implementation (Chapter 18.1) asked whether you shared PHI lawfully and obtained consent to start. Planning (Chapter 7.1) asked you to name a proxy and write a POLST. Evaluation asks a different question: after you looked at what happened, was the plan still ethically justified, who now decides, and whose outcome did you never measure?

ANCC will not ask you to lecture on Beauchamp and Childress. It will give you a 79-year-old who refuses dialysis after you explain the creatinine, a 15-year-old who will not assent to a needed incision and drainage, a son who wants a feeding tube the patient previously refused, or a panel of missed mammograms that all live on one bus line. The scored move is the next ethical action after the data.

The four principles applied after the result

Autonomy, beneficence, nonmaleficence, and justice are not a planning-only checklist. At evaluation you re-run them against what actually occurred.

A plan that was autonomous at week 0 can fail autonomy at week 8 if delirium, a new stroke, or untreated depression has erased capacity. A plan that was beneficent on paper can fail nonmaleficence when the ACE inhibitor drops eGFR 40% or the SSRI precipitates mania. Re-consent is an evaluation skill, not a courtesy. The frail 88-year-old who agreed to tight A1c targets in April and now falls after two hypoglycemic spells has a new ethical problem even if HEDIS still smiles.

Capacity is clinical; competence is a court finding

Decision-making capacity is a clinical determination you make for this decision at this time. It is decision-specific and can fluctuate with the clock, the oxygen saturation, and the last dose of hydromorphone. Competence (many statutes now say incompetence or use “incapacitated person”) is a judicial determination. You do not “declare someone incompetent” in the progress note and then ignore them. You document a capacity assessment, treat reversible contributors, and — if they lack capacity for this decision — activate the legally authorized decision-maker.

Assess the four functional abilities (the Appelbaum framework is the usual U.S. teaching model):

1. Understand the information — diagnosis, recommended intervention, alternatives, and risks, in language the person can use.
2. Appreciate that the information applies to them (not “people with kidney failure,” but “my kidneys”).
3. Reason — weigh options in a way that is consistent with their values, even if you disagree with the choice.
4. Communicate a stable choice.

A patient may have capacity to refuse a statin and lack capacity to refuse emergency surgery the same afternoon. Depression, psychosis, intoxication, hypoxia, hepatic encephalopathy, and hypoactive delirium are common reversible destroyers of capacity. Treat the reversible cause and reassess before you lock in a surrogate decision. A Mini-Cog or MoCA screens cognition; it does not by itself equal a capacity determination. A passing clock-draw does not authorize you to skip the four abilities, and a failed screen does not automatically hand the decision to the first relative in the waiting room.

Informed refusal is valid only after you have evaluated that the patient understands the risk they are accepting. The evaluation-stage note is not “patient refused.” It is: what you explained (including the likely outcome of doing nothing), how you confirmed understanding (teach-back), that the choice was voluntary, that capacity was present, what you offered instead, and when you will re-open the conversation. A signature on a blank refusal form without that assessment is not protection and is not ethical care. If the person later loses capacity, that documented refusal still speaks — you do not restart the refused intervention just because a surrogate prefers it.

Lifespan notes on capacity

An infant or preschooler has no capacity for medical decisions; the parent or guardian decides, constrained by the child’s best interest and by abuse/neglect law. A school-age child may understand pieces and should be asked; they still do not hold legal authority for most care. An adolescent may have adult-level capacity for a specific decision even when the parent still holds legal permission — that tension is why assent exists. A young adult with an intellectual disability may have capacity for some decisions and a guardian for others; read the letters. An older adult with mild cognitive impairment often retains capacity for ordinary primary-care choices. A frail patient with hypoactive delirium after pneumonia often does not — treat the pneumonia and the constipation before you rewrite the advance directive.

Guardianship, proxy, and the surrogate hierarchy

When the patient lacks capacity, you do not invent a family vote. You follow state law. Typical U.S. hierarchy, which varies by statute — say so on the exam:

A guardian of the estate (money) is not automatically a guardian of the person (health). A spouse who is legally separated may not be first. Unmarried partners and close friends are recognized in some states and invisible in others. Do not let the loudest adult child override a valid proxy. Do not treat a notarized living will as a portable medical order — that is what POLST/MOLST is for (Chapter 7.1). Evaluation is when you notice the POLST and the hospital code status disagree; you reconcile them with the decision-maker instead of picking the one that is convenient for the rounding team.

If two children disagree and there is no named proxy, you do not pick the child who wants “everything.” You convene, clarify the patient’s known values, and request a bioethics consult. If the conflict is intractable, the institution’s counsel and, if needed, the court — not a unilateral FNP override — resolve standing. Document who you identified as the legal decision-maker and why. “Family at bedside” is not a legal category.

Pediatrics: permission, assent, emancipation, mature minor

Children do not sign the same consent you use for a 40-year-old. Parental permission authorizes treatment for the minor (with the usual emergency exception when delay would harm the child and no parent is available). Assent is the child’s affirmative agreement, scaled to development. A 5-year-old gets a simple explanation and a chance to say what they fear. A 14-year-old gets a real description of the procedure, alternatives, and aftercare, and you document whether they assent.

Dissent from a school-age or adolescent patient is ethically weighty even when the parent has legal authority. You do not physically wrestle a 15-year-old to the table for an elective I&D because a parent is in a hurry. Pause, treat pain and fear, involve child-life or a trusted adult, and escalate to ethics or child-protection only if the delay itself is harmful and the intervention is necessary. Emergency stabilization of a deteriorating child is not “elective I&D.” A slowly enlarging, well-localized abscess in a well-appearing teen usually can wait an hour for trust.

Emancipated minors (court order, lawful marriage, and in many states active-duty military service; some states add living independently and self-supporting) generally consent as adults for their own care. Mature-minor doctrine is state-specific: some states and courts allow an unemancipated adolescent who demonstrates capacity to consent to certain care. State minor-consent statutes separately allow many adolescents to consent to STI care, contraception, prenatal care, and some mental-health or SUD services without parental permission (Chapter 18.1). Evaluation-stage trap: a parent demands the adolescent’s chlamydia result “because I pay the bill and we are reviewing the plan.” If state law gave the minor control of that slice of care, you do not release it just because you are in an evaluation visit.

A pregnant adolescent’s capacity to consent to pregnancy-related care is also state-specific. Do not invent a nationwide age. Do not assume the infant’s father, the school nurse, or the grandmother automatically becomes the decision-maker.

When to stop a futile or harmful plan

Physiologic futility means the intervention cannot achieve its physiologic goal (CPR in the presence of dependent lividity; antibiotics for a confirmed uncomplicated viral syndrome will not change the viral course). Qualitative futility is more contested: the intervention may change a number but cannot achieve a goal the patient would recognize as a benefit (long-term dialysis in a patient whose stated goal was to die at home without machines).

The FNP does not label a plan “futile” because it is expensive, because the family is difficult, or because you would not choose it for yourself. You do stop or refuse to continue when:

• Harm is occurring and the goal is no longer achievable (recurrent hypoglycemia from pushing A1c below the patient’s safe range; ACE-inhibitor hyperkalemia of 6.2).
• The patient with capacity withdraws consent after an evaluated, documented discussion.
• A valid advance directive or POLST forbids the intervention, and no new capacity-bearing choice has reversed it.
• You are being asked to perform a non-beneficial, harmful procedure you cannot justify (Chapter 18.4 scope).

Document the clinical basis, the conversation, the offer of palliative goals that can run with or instead of disease-directed treatment, and the ethics consult if disagreement persists. “We don’t do that here” without an explanation is not an evaluation. Hospice language from Chapter 7.1 still applies: comfort-focused care is a plan with outcomes (pain, dyspnea, caregiver support), not an abandonment.

Justice after the fact: who never got the screen

Justice at evaluation is not a slogan. It is an audit. If your diabetic panel’s A1c control looks excellent because the uninsured patients never came back, you did not evaluate well — you selected the easy denominator. SDOH (transportation, language, broadband, food, housing, coverage, immigration fear, shift work) explain missed mammograms, unfinished H. pylori regimens, and “nonadherent” CPAP as often as motivation does.

The scored move is to name the barrier and change the plan: navigation, a closer imaging site, a language-concordant visit, a 90-day fill, a mail-order option, a Saturday slot, or a public-health referral — not another lecture on willpower. Population justice also includes overtreatment: offering a low-value screen to a frail 89-year-old because a HEDIS alert fired, while the 52-year-old with no ride never received her first mammogram. Both are evaluation failures. One harms by omission, the other by commission.

Track who is missing the way you track a critical potassium: name, barrier, next outreach, and a date you will look again. A registry that cannot stratify by language, payer, or no-show reason will hide injustice as “noncompliance.”

When to call a bioethics consult

Call ethics when stakeholders disagree about goals, when capacity is uncertain and the stakes are high, when a surrogate appears to decide against the patient’s known values or for a conflict of interest (inheritance, immigration sponsorship, a caregiver who is exhausted and asking you to “just make this stop” in a way that is not the patient’s goal), when a staff member is being asked to participate in care they believe is harmful, or when cultural or religious commitments collide with a recommended plan and you cannot reconcile them in the room. Ethics consults clarify facts, values, and options. They do not write your note for you and they do not replace state law or a valid proxy.

If you remember one Domain V ethics sentence: re-check capacity, honor the legally authorized voice, document the informed refusal, stop what is now harming, and ask whose outcome never entered the chart.