Purpose of review <p>Emergency medicine physicians (EMP) are routinely called upon to assist patients and their families in making serious, often life altering, medical decisions. These decisions are regularly made with limited information and during times of crisis. With patient autonomy at the forefront of EMPs minds, this review provides both background and pragmatic approaches to the evaluation of the older adult patient’s capacity to participate in this medical decision-making process. It is important for the reader to recognize this article is meant to provide an overview of the literature in an effort to educate clinicians who care for older adult patients. It should be viewed as a medical reference. As the clinical care of patients can be impacted by many variables, this article should not be seen as an effort to strictly define the standard of care for all medical providers in all settings.</p> Recent Findings <p>The landscape of emergency medicine (EM) continues to evolve in the post-COVID era. With recent increased focus on high-value, often ambulatory based care and continued emphasis on patient autonomy, medical decision-making capacity evaluations are being considered within contemporary contexts. This article aims to summarize the approach to these evaluations within the modern-day practice environment of EM.</p> Summary <p>Caring for older adults in the emergency department (ED) is common and becoming more so. As such, there is a need for EMPs to be well versed in capacity evaluations among this cohort. The T.A.S.K approach, establishing trust, asking about the key capacity elements, considering said elements within the context of the sliding scale principle and keeping an accurate and concise record of the evaluation is one method EMPs might employ when conducting such assessments. It is further important for the EMP to recognize the unique biopsychosocial aspects among older adults that can influence the process and results of this capacity evaluation.</p>