An 86-year-old woman with Alzheimer disease is brought to the emergency department by her son due to worsening cough and fatigue; she is found to have pneumonia. The physician explains the diagnosis and treatment plan, including hospitalization for intravenous antibiotics. The patient replies, "I'd prefer to leave. I'm more comfortable at home." She asks to be discharged with oral antibiotics. The physician explains that intravenous antibiotics are preferred and that the risks of worsening infection may include sepsis and death. The patient appreciates the risks involved and says, "I will come back to the hospital if I feel worse; I just don't like to stay in the hospital." The patient is widowed and lives with her son, who insists that she stay in the hospital for treatment. He reports that his mother has been increasingly forgetful and has gotten lost several times while walking in the neighborhood. On mental status examination, the patient is alert and oriented. Mini-Mental State Examination score is 24, indicating mild cognitive impairment. Which of the following is the most appropriate next step in the managment of this patient?

Question

An 86-year-old woman with Alzheimer disease is brought to the emergency department by her son due to worsening cough and fatigue; she is found to have pneumonia.  The physician explains the diagnosis and treatment plan, including hospitalization for intravenous antibiotics.  The patient replies, "I'd prefer to leave.  I'm more comfortable at home."  She asks to be discharged with oral antibiotics.  The physician explains that intravenous antibiotics are preferred and that the risks of worsening infection may include sepsis and death.  The patient appreciates the risks involved and says, "I will come back to the hospital if I feel worse; I just don't like to stay in the hospital."  The patient is widowed and lives with her son, who insists that she stay in the hospital for treatment.  He reports that his mother has been increasingly forgetful and has gotten lost several times while walking in the neighborhood.  On mental status examination, the patient is alert and oriented.  Mini-Mental State Examination score is 24, indicating mild cognitive impairment.  Which of the following is the most appropriate next step in the managment of this patient?

Quizplus · Accepted Answer

11ec160b_3658_990b_9249_b1b4f8fc7893_MD0001_00 Patients with decision-making capacity have the right to refuse treatment based on the ethical principle of autonomy. Although this patient has Alzheimer disease (AD), her cognitive impairment is mild (ie, Mini-Mental State Examination score of 24), and she meets the 4 requisite criteria for decisional capacity: ability to communicate her choice, understand her medical condition, appreciate the potential consequences of her decision, and provide a rationale for her decision (eg, being more comfortable at home). Patients with AD who have only mild cognitive impairment often retain decision-making capacity; a diagnosis of AD by itself is not a reason to assume the patient lacks capacity to give consent or refuse treatment. Conditions that may impair capacity include delirium, moderate to severe cognitive impairment, psychosis, and severe depression. (Choices A and D) This patient has demonstrated capacity to make the decision to be treated at home with oral antibiotics, and her autonomy should be respected. Consulting the hospital ethics committee is reserved for complex situations and disputes (eg, family members unable to agree on a decision for an incapacitated patient). A second physician opinion to assess decision-making capacity is not necessary. (Choices B and C) The right to refuse treatment in a patient with intact decision-making capacity overrules any family member's preference. The son, as next of kin, would serve as surrogate decision maker only if the patient lacked capacity and there was no advance directive to guide care. Educational objective: The capacity to refuse treatment requires the ability to express a choice, understand the relevant medical information, appreciate the potential consequences of treatment options, and offer a rationale for the decision. Patients with Alzheimer disease in the mildly affected range often retain decision-making capacity. __________ References: Assessment of healthcare decision-making capacity. (http://www.ncbi.nlm.nih.gov/pubmed/27551024)

An 86-Year-Old Woman with Alzheimer Disease Is Brought to the Emergency