The 4–4–4 approach: A practical framework for capacity assessments

Introduction: Many physicians lack the understanding or experience to assess capacity with confidence. The goal of this review is to provide an easily applicable, practical approach to capacity assessments. Methods: Published literature on capacity assessments was reviewed. Database searches were conducted to retrieve relevant research articles published between 1985 and 2025. Discussion: The 4–4–4 approach combines the four foundational skills of capacity assessments with four practical rules and then applies these to four common capacity scenarios. While the four foundational skills for capacity ( U nderstand, A ppreciate, R ationalize, E xpress, or “UARE”) are well known, many physicians remain uncomfortable with assessing capacity. We propose, in addition to UARE, the application of four practical rules: 1. A trigger must be present, 2. Functional assessment is essential, 3. Capacity is task-specific, and 4. Past history and future risks must be considered. The four most common types of capacity scenarios are then discussed, and we illustrate the application of these rules to four common clinical scenarios to improve appropriateness of and confidence in capacity assessments.