A 73-year-old woman is seen in the hospital following emergent left transmetatarsal amputation. The patient has a history of chronic, nonhealing foot ulcers due to poorly controlled diabetes mellitus and peripheral artery disease and was admitted 2 days ago with wet gangrene and cellulitis. At the time of admission, she had fever, hypotension, and altered mental status, and consent for amputation was provided by her son who is her designated surrogate decision maker. Following surgery, the patient has been stabilized with intravenous antibiotics, opioid pain medications, and appropriate thromboembolism prophylaxis. When the vascular surgeon explains his recommendation for left lower extremity angiography and possible revascularization to prevent further amputation, the patient refuses the procedures. She says, "I'm too old for another operation. I didn't want surgery the first time, and I don't want it now." Which of the following is the most appropriate next step in management of this patient?

Question

A 73-year-old woman is seen in the hospital following emergent left transmetatarsal amputation.  The patient has a history of chronic, nonhealing foot ulcers due to poorly controlled diabetes mellitus and peripheral artery disease and was admitted 2 days ago with wet gangrene and cellulitis.  At the time of admission, she had fever, hypotension, and altered mental status, and consent for amputation was provided by her son who is her designated surrogate decision maker.  Following surgery, the patient has been stabilized with intravenous antibiotics, opioid pain medications, and appropriate thromboembolism prophylaxis.  When the vascular surgeon explains his recommendation for left lower extremity angiography and possible revascularization to prevent further amputation, the patient refuses the procedures.  She says, "I'm too old for another operation.  I didn't want surgery the first time, and I don't want it now."  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d74e_6aad_bc81_41d74e4c9242_MD0003_00 This patient's mental status has improved; however, it is not clear whether she has fully regained capacity to make her own health care decisions. Although it was appropriate for her son to act as a surrogate decision maker to consent for the amputation when she was clearly incapacitated, the patient is now refusing further procedures. The most appropriate next step is to reassess her decision-making capacity. Factors potentially affecting her cognition such as delirium (due to infection or metabolic derangements) and cognitive effects of opioid pain medication should be considered. If the patient has regained capacity, her decision must be respected and supersede the wishes of any surrogate decision maker. Components of capacity include understanding the condition, ability to express a choice, appreciation of the consequences of treatment options (including no treatment), and ability to provide reasoning for the decision. If the patient meets these criteria, it is her right to refuse treatment. (Choices A and C) These options can only be considered if a capacity reassessment determines that the patient still lacks decision-making capacity. If the patient has regained capacity to make decisions, her wishes supersede the wishes of the son or any instructions documented previously in a living will. (Choice B) Assessment of the patient's decision-making capacity is the critical determinant of the next step in her medical management. If her capacity is in question, then it is reasonable to determine if depression is affecting her judgment. (Choice E) This patient was recently incapacitated. Assessment and documentation that she has regained capacity should be performed before accepting her decision as an informed refusal. (Choice F) Two-physician consent is used in some states when there is no living will or surrogate available to make decisions for a patient without capacity. Educational objective: Incapacitated patients may regain capacity as their condition improves. These patients should be reassessed for capacity before health care decisions are made. References: The issue of consent in medical practice. (http://www.ncbi.nlm.nih.gov/pubmed/26564240) Assessment of healthcare decision-making capacity. (http://www.ncbi.nlm.nih.gov/pubmed/27551024)

A 73-Year-Old Woman Is Seen in the Hospital Following Emergent