An 84-year-old man with a long history of obesity, diabetes, and peripheral artery disease is hospitalized for an extensive gangrenous ulcer on his right foot. A surgical consultant recommends urgent below-the-knee amputation as a life-saving procedure. The patient refuses, saying, "I've had a long life. Most of my friends are dead and all I have left are memories." He does not want to undergo any type of surgical procedure and prefers to be treated with medications only. His primary care provider is uncomfortable with this decision as the patient seems forgetful.
On evaluation and record review, there is no evidence of delirium or psychosis. The patient is sad about the death of several friends over the past year. His appetite is normal and he reports no changes in sleep. He is able to provide a summary of his medical condition and acknowledges that refusing surgery may result in his death. His score on a Montreal Cognitive Assessment is 24/30.
Which of the following is the most appropriate course of action?

Question

An 84-year-old man with a long history of obesity, diabetes, and peripheral artery disease is hospitalized for an extensive gangrenous ulcer on his right foot.  A surgical consultant recommends urgent below-the-knee amputation as a life-saving procedure.  The patient refuses, saying, "I've had a long life.  Most of my friends are dead and all I have left are memories."  He does not want to undergo any type of surgical procedure and prefers to be treated with medications only.  His primary care provider is uncomfortable with this decision as the patient seems forgetful.
On evaluation and record review, there is no evidence of delirium or psychosis.  The patient is sad about the death of several friends over the past year.  His appetite is normal and he reports no changes in sleep.  He is able to provide a summary of his medical condition and acknowledges that refusing surgery may result in his death.  His score on a Montreal Cognitive Assessment is 24/30.
Which of the following is the most appropriate course of action?

Quizplus · Accepted Answer

11ec193a_970d_6dff_853d_7943ab4fa4cc_MD0002_00 Determination of patients' capacity to make medical decisions requires establishing a balance between respecting patient autonomy and protecting those with cognitive impairment. Patients who refuse treatment should be assessed for decision-making capacity according to the criteria in the table. The physician does not have to agree with a patient's decision provided the patient demonstrates consistent, logical reasoning. This patient has decision-making capacity. He is able to articulate reasons for his decision and shows no signs of delirium, psychosis, or severe depression that could interfere with his ability to understand the information and appreciate the risks of refusing surgery. He has the right to refuse treatment and his decision should be respected. Although he may have mild cognitive impairment, as evidenced by his Montreal Cognitive Assessment (MoCA) score of 24/30, there is no evidence that his ability to understand the specific consequences of his decision is impaired. MoCA scores <26/30 generally indicate mild cognitive impairment; however, there is no single score with high sensitivity and specificity to assess capacity. (Choice A) This patient expresses sadness associated with the loss of his friends but does not exhibit other symptoms of depression. There is no evidence that his mood has impaired his decision-making capacity regarding surgery. (Choice B) There is no evidence of impairment in decision-making capacity. Furthermore, there is limited evidence for significant benefit of cholinesterase inhibitors in mild cognitive impairment. (Choice C) Psychiatric consultation regarding capacity would be appropriate for complex cases in which the physician suspects that the patient's decision-making is compromised due to psychosis, depression, or cognitive impairment. (Choice E) This patient has decision-making capacity. If it were determined that he does not have decision-making capacity, the next step would be to contact a family member for surrogate decision-making regarding the surgery. Educational objective: Capacity to consent to or refuse treatment requires the ability to express a choice, understand the relevant medical information, appreciate the consequences of treatment options, and offer a rationale for the decision. Patients with decision-making capacity have the right to refuse medical treatment. Physicians must adhere to these decisions regardless of what they believe to be the best choice. __________ References: Assessment of decisional capacity: prevalence of medical illness and psychiatric comorbidities. (http://www.ncbi.nlm.nih.gov/pubmed/25355466) Assessment of capacity for medical decision making. (http://www.ncbi.nlm.nih.gov/pubmed/20349850)

An 84-Year-Old Man with a Long History of Obesity, Diabetes