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Difficulty: MediumInformed Consent and Refusal

A 54-year-old man is admitted to the medical ward for treatment of a severe diabetic foot ulcer. The patient has a 20-year history of type 2 diabetes mellitus and poorly controlled schizophrenia. Over the past 48 hours, the ulcer has progressed to wet gangrene, and the surgical service recommends a below-the-knee amputation to prevent life-threatening systemic infection. When the surgical team discusses the procedure, the patient adamantly refuses. He states, "I know my foot is rotting and that I could die from the infection if it spreads. But I need my legs to walk to the park, and I would rather die than be confined to a wheelchair."

On mental status examination, the patient is alert and oriented to person, place, and time. He admits to hearing auditory hallucinations telling him that the hospital food is poisoned, but he clearly states that these voices are not influencing his decision regarding his leg. He is able to accurately repeat the risks, benefits, and alternatives of the surgery, as well as the risks of refusing it.

Which of the following is the most appropriate next step in management?

  1. Honor the patient's refusal and continue maximizing medical management and wound care on the inpatient unit.Answer
  2. B
    Petition the court to declare the patient legally incompetent so the amputation can proceed.
  3. C
    Contact the patient's estranged sibling to obtain surrogate consent for the amputation.
  4. D
    Discharge the patient home against medical advice with a prescription for oral antibiotics.
  5. E
    Perform the amputation immediately under the doctrine of emergency implied consent.

Answer

Honor the patient's refusal and continue maximizing medical management and wound care on the inpatient unit.
The correct answer is to honor the patient's refusal and continue alternative medical care. To have clinical decision-making capacity, a patient must be able to communicate a choice, understand the provided information, appreciate the consequences of their decision, and reason logically based on their own values. This patient meets all criteria: he understands his foot is gangrenous, appreciates that he might die without surgery, and bases his refusal on a clear personal value (not wanting to be in a wheelchair). A history of schizophrenia—even with active hallucinations—does not automatically eliminate capacity, as long as the psychotic symptoms (in this case, paranoia about hospital food) are separate from and do not influence the specific medical decision at hand. Because the patient has capacity, his autonomy must be respected.

Step-by-Step Solution

1
Assess the patient's decision-making capacity.
The patient understands his condition, appreciates the risks of refusing treatment (including death), reasons logically based on his personal values (valuing walking over prolonging life), and clearly communicates his choice.
Capacity must be established before determining whether to honor a refusal of life-saving care.
2
Evaluate the impact of the patient's psychiatric illness on his decision.
Although the patient has active auditory hallucinations related to his schizophrenia, these delusions do not impair his reasoning regarding his gangrenous foot.
A psychiatric diagnosis only invalidates capacity if the symptoms directly interfere with the specific medical decision being made.
3
Determine the appropriate disposition given the refusal.
The patient is offered alternative, non-surgical care (antibiotics, wound care) while remaining in the hospital.
Refusing one recommended treatment does not mean the patient must be discharged or denied other appropriate medical interventions.

Key Concept

Clinical Decision-Making Capacity in Psychiatric Patients
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Topics

Informed Consent and Refusal

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