A 74-year-old man comes to the hospital due to weight loss, fatigue, and blood in the stools. Review of systems is positive for a change in bowel habits. Further evaluation reveals localized colon carcinoma. The patient is told the diagnosis and is educated about his prognosis and treatment options, including surgery; he listens carefully and asks no questions. He is a high school graduate and worked in an automotive factory until retirement; he and his wife have been active in his retirement community. The patient appears to comprehend the information without difficulty. He says, "I've lived long enough, and I do not want surgery or treatment of any kind." The patient is accompanied by his wife, who agrees with the physician's recommendation for surgery. Which of the following is the most appropriate next step in addressing this situation?

Question

A 74-year-old man comes to the hospital due to weight loss, fatigue, and blood in the stools.  Review of systems is positive for a change in bowel habits.  Further evaluation reveals localized colon carcinoma.  The patient is told the diagnosis and is educated about his prognosis and treatment options, including surgery; he listens carefully and asks no questions.  He is a high school graduate and worked in an automotive factory until retirement; he and his wife have been active in his retirement community.  The patient appears to comprehend the information without difficulty.  He says, "I've lived long enough, and I do not want surgery or treatment of any kind."  The patient is accompanied by his wife, who agrees with the physician's recommendation for surgery.  Which of the following is the most appropriate next step in addressing this situation?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d52e_704d_bc81_3f6f783dc477_MD0003_00 When patients refuse treatment for serious illness, it is important to assess their decision-making capacity (DMC). DMC has 4 primary components: Ability to clearly communicate a choice Understand the information provided Appreciate the consequences of the choice Provide a rationale for the decision. This patient is clearly communicating his choice to decline treatment for cancer. He does not have any obvious impairment in mental function and appears to understand the diagnosis and treatment options. In addition, he appears to appreciate the consequences of refusing curative treatment, including risk of death (implied in his statement, "I've lived long enough"). However, the specific rationale for this patient's refusal has not been adequately explored. For example, a patient may be afraid of pain during surgical procedures, a fear that could be based on inaccurate or incomplete information (eg, lack of knowledge about newer, less invasive surgical options). Personal values and cultural beliefs may also play a role. In some patients, mental health issues (eg, hopelessness due to depression) may be a contributing factor. Therefore, the physician should explore and clarify the patient's rationale for his decision. If he is able to fully explain his rationale for declining treatment, demonstrating that he has made an informed decision, then his decision should be respected and treatment withheld. (Choice A) This patient appears to have the capacity to make informed decisions about his care. Therefore, it would be inappropriate to ask family members to pressure him into accepting treatment. (Choices C and D) If the patient still refuses treatment after his rationale is clarified, he should be offered ongoing follow-up with the opportunity to reconsider his decision. However, discharging him without first understanding his rationale for treatment refusal can lead to unnecessary treatment delays and increase the risk that the patient may be lost to follow-up. (Choice E) Cognitive screening tools (eg, Montreal Cognitive Assessment) are sensitive for detecting cognitive impairment (eg, dementia screening). However, this patient shows no signs of impairment, and it is more important to understand his rationale for treatment refusal. Educational objective: When assessing decision-making capacity (such as in refusal of treatment), the physician must ensure that the patient clearly communicates their choice for care, understands the information provided regarding diagnosis and treatment, appreciates the consequences of treatment or refusal, and can explain the rationale for their decision.

A 74-Year-Old Man Comes to the Hospital Due to Weight