Examkin

Question

Difficulty: MediumDecision-Making Capacity

A 72-year-old man is evaluated in the clinic to discuss the results of a recent colonoscopy. Biopsies of a large cecal mass confirm adenocarcinoma. The patient has a history of hypertension, type 2 diabetes mellitus, and mild Alzheimer dementia. His physical examination is unremarkable. The physician recommends surgical resection of the mass. The patient states, "I understand that I have cancer in my colon and that without surgery, it will eventually spread and end my life. However, I watched my brother suffer through multiple complications after major abdominal surgery. I am 72 years old, my memory is starting to fail, and I want to spend whatever time I have left comfortably at home with my wife, not recovering in a hospital." The patient's son, who is his designated healthcare proxy, is present at the visit and strongly disagrees, insisting that the physician schedule the surgery immediately. Which of the following is the most appropriate next step in management?

  1. A
    Request a psychiatric consultation to officially determine the patient's legal competence.
  2. B
    Defer to the son's decision to proceed with surgery because he is the designated healthcare proxy.
  3. Honor the patient's refusal of surgery and arrange for palliative-focused care.Answer
  4. D
    Admit the patient to the hospital to expedite a preoperative evaluation against his wishes.
  5. E
    Determine that the patient lacks capacity based on his dementia diagnosis and proceed with the son's request for surgery.

Answer

Honor the patient's refusal of surgery and arrange for palliative-focused care.
The correct answer is to honor the patient's refusal and arrange for palliative-focused care. This patient demonstrates all four pillars of decision-making capacity: he understands his condition (colon cancer), appreciates the consequences of his decision (the tumor will spread and cause death), reasons based on his own values (prioritizing quality of life over surgical recovery, based on his brother's experience), and clearly expresses a choice. A diagnosis of mild dementia does not automatically preclude capacity, as capacity is decision-specific. When a patient has intact capacity, their autonomous decision must be respected, even if it results in death or conflicts with a surrogate's wishes.

Step-by-Step Solution

1
Assess whether the patient possesses the four components of decision-making capacity.
The patient successfully demonstrates understanding of his diagnosis, appreciation of the consequences of refusing surgery, reasoning based on his personal values, and clearly expresses a choice.
Capacity must be established clinically whenever a patient refuses a standard or life-saving medical intervention.
2
Evaluate the impact of the patient's dementia diagnosis on his capacity.
The patient retains decision-making capacity for this specific intervention despite having mild Alzheimer dementia.
A psychiatric or neurocognitive diagnosis does not automatically negate decision-making capacity; capacity is a decision-specific clinical assessment.
3
Determine the legal standing of the healthcare proxy (the son).
The surrogate decision-maker is not activated.
A healthcare proxy only assumes decision-making authority when the primary patient loses decision-making capacity.

Key Concept

Decision-Making Capacity
Rate this question

Topics

Decision-Making Capacity

More questions from this topic